The claim of denial is not final; therefore, take a deep breath, relax, and sit down for a cup of coffee. This article may be the solution you need to guide you through finding a free medical claim.
collect information
Collect all documents related to your medical claim; for example, your insurance policy, rejected claims, letters you receive from doctors and insurance companies, and more.
Check and understand the reason for the claim rejection
Read the claim EOB [welfare statement] sent by the insurance company because you will see the reason for the rejection. Most of the time, claims will be rejected for the following reasons:
• Errors in submitting a claim form [such as a doctor's office] fail to use the correct or registered NPI [National Provider Number], the wrong claim form used, the wrong service location for the program, the wrong diagnostic code, and so on. In this case, the doctor's office only needs to submit a corrected claim in order to adjust and pay for your medical claim.
• Rejected due to pre-existing conditions. The insurance company will send you a letter asking you to provide a list of providers you have seen within a certain time frame so that they can contact your health care provider. Request your medical records and the review department will conduct a pre-existing review. If they find that the diagnosis of the medical procedure performed is indeed one of the conditions that existed during your waiting period, your claim will be eventually rejected. Often, because insurance companies are still waiting for members to respond to requests or medical records, some claims have to wait a few months for pre-screening.
• Rejected due to pre-certification. This means that the medical service performed is a covered service; however, it should be approved before it is approved. The medical institution or doctor's office must call the pre-certification department of the insurance company before performing the service. Often, services that require approval include 24-hour hospitalization, expensive diagnostic services such as MRI and CAT scans, mental health services, and expensive durable medical equipment. If for some reason no pre-certification of the program or device is obtained, your health care provider can call the pre-certification department and obtain a retroactive pre-certification and resubmit the claim.
• Rejected due to no prior decision. This is a program in which a member's request/approval provider will send the insurer's medical records and recommended medical tests, medical equipment and non-emergency procedures to the insurance company. These procedures are usually very expensive, such as breast reconstruction. And weight loss surgery.
• Rejected due to timely submission. The time limit for filing a claim depends on whether the medical procedure is performed by a non-contracted provider and your state. Usually six months from the date of service. It may be that your health care provider issued a claim before submitting the application in time, there is a computer failure in the insurance company's system, and they only received a refilled claim. So please take the time to contact your provider and know when they will submit their claim for the first time. If they can present a copy or proof of timely submission, you can ask them to resubmit the claim.
• Refused due to eligibility. This usually happens in newborns who have not yet joined the policy. Just call your insurance representative and adjust your claim by phone. For most states, newborns are protected by a mother's policy within the first 30 days of life.
• Rejected due to COB [interest of the agreement]. If you have another insurance company as your primary insurance company, your claim needs to be addressed to the primary insurance company and a copy of the EOB should be sent to the secondary insurance company so that you can process the claim.
Contact insurance company
Now that you understand and understand why your claim was rejected, please write down the information you need, such as your insurance account number, pre-certification or prejudice reference number, the date the claim was originally submitted, the medical record, and any information related to it. Your claim is a problem. Call your insurance account representative [it takes time to get to the on-site agent, so stay calm]. Discuss your claim with your insurance representative; why you think it is incorrect and clearly provide your support information. Ask to review or adjust your claim. Always ask for the number of days you have to wait before resolving, and then you can call back for follow up. In addition, a phone reference number is required so that when you call back your claim, you simply send your phone number to the next representative who answers the call and he or she can pick up your phone number. Account records and documents are immediate. This will help you save time and quick and easy service.
Record your conversation with the representative. Get their employee ID number and record the time and date of your call. Write down what you said in the conference call.
File a complaint with the disputed department
If your claim is still unresolved, you can file a complaint. You can write to the insurance complaints department or fax it. There is a timely application date, which depends on the state you are in. Just ask your agent. You can call your insurance representative to ask for an appeal and submit your application limit and address in a timely manner.
Orignal From: Refusing medical insurance claims: a quick and easy solution!
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