Category >> Health >> Health insurance claims - Applying for an external review
Health insurance claims - Applying for an external review

Often your health insurance claims can run into problems that can leave you puzzled. The first step to resolution is to know what went wrong. A claim can be rejected if the insurance company considers it to be inauthentic. It may so happen that the policy taken by you or your employer does not cover the service mentioned in the claim. You have opted for elective or an experimental procedure which is not covered by the insurance providers.

If you are sure of the veracity of your claim then by all means go ahead and contest the denial of payment. Request an external review through your state’s external review program. The program covers individually purchased coverage and coverage through your employer. In fact, in some states in the USA you can authorize your doctor to appeal on your behalf against the denial.

If your employer is offering “self-funded” coverage, i.e. the employer is absorbing coverage costs then in that case you may not be able to obtain an external review. The same applies if you have opted for a Medicare or a Medicaid health insurance policy. These policies are governed by their own rules and are not open to an external review.

You will need to have some information in place in order to initiate an external review. These include copies of your insurance ID card, the letter from the insurance company stating that you have been denied claim settlement, medical records relevant to the claims in question, etc.

You may have to pay a fee to file for the external review; this fee varies with the state. You can easily check for the amount payable by searching online. You can also log on to the website of your state’s insurance department for deeper understanding of how the external review process works. The timeframe for completing a review depends upon the urgency. An urgent review may take around 72 hours to get completed whereas a non-urgent standard review can take 30 days to reach conclusion; however even these timeframes vary with the state.

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