Introduction to the Problem
Trying to figure out why a health insurance claim was denied can be a time-consuming and frustrating process. Anna Deutscher, a 29-year-old from Minnesota, experienced this firsthand when her son Beckham’s hearing tests were not covered by their insurance. As part of his diagnosis with congenital CMV, a virus that can cause hearing loss, Beckham requires routine hearing tests every few months until he is 10 years old. Despite these tests being considered preventive care, which is supposed to be covered by law, Deutscher’s insurance company denied the claims, leaving the family with significant out-of-pocket expenses.
Understanding the Issue
Deutscher’s situation is not unique. Many people struggle to navigate the complex health insurance system and may feel overwhelmed by the process of appealing a denied claim. However, it is essential to remember that preventive care, such as hearing tests, is supposed to be covered without additional cost under the Affordable Care Act. If you receive a recommended preventive screening and have private insurance, including through the Affordable Care Act marketplace, there should be no copayment at the time of service, and you shouldn’t get a bill later.
Steps to Take When a Claim is Denied
If you find yourself in a situation like Deutscher’s, there are several steps you can take to appeal the denied claim.
1. Check Your Policy
Read your plan documents to confirm whether the treatment or service is covered. Pay attention to any exclusions or limitations.
2. Determine if the Service is Preventive
Many types of preventive care are supposed to be covered without additional cost under the Affordable Care Act. Check with your employer’s human resources benefits manager to find out if your plan is "grandfathered in," which may affect your rights and protections.
3. Understand the Denial
If you’ve been denied coverage, you need to know why. Health insurance companies are required to explain every denial. The denial letter or your explanation of benefits should state the reason, which may be a coverage exclusion, incorrect coding, or a determination that the service was deemed not medically necessary.
4. File an Appeal
There are a few steps to know, but you don’t have to be a lawyer to figure them out. Usually, there’s an appeal form to fill out. Visit your insurer’s website, check your explanation of benefits, or call your insurer and ask how to get started. The process typically includes writing a letter saying why you disagree with the denial. Include any medical records or test results that support your case and a copy of the federal guidelines that show the care is a covered, preventive service.
5. Seek Help from Human Resources
If you get coverage through your job and you’re hitting roadblocks, consider emailing your human resources department. HR folks have contacts with the insurance companies you don’t and may save you a few calls to the 800 number on the back of your insurance card.
Conclusion
Navigating the health insurance system can be challenging, but it’s essential to remember that you have the right to appeal a denied claim. By following the steps outlined above, you can advocate for yourself and ensure that you receive the coverage you are entitled to. Deutscher’s experience shows that persistence and seeking help from the right resources can make a significant difference. With the right approach, you can overcome the hurdles and get the care you need.
Frequently Asked Questions
- Q: What should I do if my insurance company denies my claim for a preventive service?
A: You should appeal the denial by following the steps outlined in your plan documents and explanation of benefits. - Q: How do I know if a service is considered preventive care?
A: Check the healthcare.gov list of recommended preventive services or consult with your physician to determine if the service is considered preventive. - Q: Can I seek help from my human resources department if I’m having trouble with my insurance claim?
A: Yes, your HR department may be able to assist you in navigating the insurance company and advocating for your rights. - Q: What is the process for filing an appeal with my insurance company?
A: The process typically includes filling out an appeal form, writing a letter explaining why you disagree with the denial, and including any supporting medical records or documentation. - Q: How long does the appeal process typically take?
A: The appeal process can take anywhere from 30 to 60 days, depending on your state and health plan.
