You’ve just had an
expensive medical procedure, and your health care plan
won’t cover it. You probably have some options to
resolve the dispute.
The best defensive against having a health care plan
from denying a claim is being informed before you
have the procedure. This includes reading your plan
description to determine if the procedure is covered,
calling your benefits administrator to ask any
questions, and communicating with your health care
provider about exactly what procedures you will
undergo.
There are several reasons a health care plan will not
cover a procedure. Here are a few of the most
common:
- Failing to get a pre-certification for
non-emergency surgery. Most insurance companies
require physicians to obtain a pre-certification
before the surgery and will send you a letter stating
that the surgery has been approved. Be sure to have a
copy of the letter before the surgery. If you
must have emergency surgery, make sure to let your
health care plan know as soon as possible. Make sure a
family member or friend has a copy of your insurance
card and is willing to call your health care provider
and your plan’s benefits administrator.
- Pre-existing conditions. If you have an individual
policy or had a lapse in coverage between group health
care plans, some conditions you were treated for in
the past may not be covered for a designated period of
time. When you change health insurance plans, be sure
to ask if any of your conditions will be considered
pre-existing and the length of time the conditions
will not be covered by your plan.
- Treatment for a condition related to an automobile
accident or on-the-job injury. Your health care plan
may not cover these incidences.
- An error made by your health care provider.
Providers and claims specialists communicate through
standardized codes that describe procedures.
Occasionally a health care provider will file a claim
with the wrong code. This error can affect the outcome
of your claim.
If you feel that your treatment qualifies to be
covered by your plan, check with your benefits
administrator to learn how to file an appeal. Under the
Employee Retirement Income Security Act (ERISA), you
have the right to appeal any benefit determination. Your
plan may allow you to appeal more than once. Your plan
is required to provide any review of your claim,
documents used to determine the claim and a copy of any
guideline used in processing your claim.
Some states have additional guidelines in addition to
the federally mandated ERISA. Details about how to
appeal a decision will be listed on the Explanation of
Benefits you received from your plan concerning your
medical claim.
ERISA also allows you to file a lawsuit against your
health care plan if your dispute is not resolved. Some
plans may require dispute resolution, such as mediation.
Church workers and government employees are not
covered under ERISA, but may have legal remedies
available to them under state law. The local office of
the U.S. Department of Labor or your state insurance
company can tell you what options are available to
you.
