Insurance denials

There are times when insurance plans do not appear to be paying very much, or deny coverage altogether. A denial of coverage means that the insurance company will not pay for medical care that will be or has been provided. Sometimes this can be due to billing or coding errors on the part of the hospital or clinic, failure to have appropriate referrals for tests or hospital admissions, assuming that a treatment is a covered benefit when it is not, and not understanding that a specific provider is "out of network." Each insurance plan and every patient is different. It is possible to appeal a denial of coverage. There are a few steps a family can take to begin this process:

• Get a written copy of the reason for denial from the insurance company. This should state the specific reason why coverage has been denied, and will give information about appealing the denial.
• Understand and follow the time limitations for appealing a denial.
• Read the Health Plan Book carefully to see if the reason for denial is consistent with what your plan says.
• Record all dates of contact with the insurance company, and the names of people that you speak with.
• Work with the financial or billing office of the hospital or clinic. They can often advocate for you, or help resolve a misunderstanding.
• A child’s doctor can write a letter of explanation or contact the health plan medical director directly to discuss a treatment or procedure.
• Work with the benefits manager or human resources office of the employer when the company is self-insured.

If there are significant, irresolvable problems, the following resources may be helpful: