Do you have any tips on filing a health benefits claim?
Yes. The first step you should take even before filing a claim is to carefully read your health plan's summary plan description (SPD). This is a document that your health plan administrator must give you after you join your health insurance plan. This plan summary will tell you how the plan works, what benefits it provides, and how the benefits may be obtained or the process for filing your claim. It should also describe your rights and protections under ERISA (Employee Retirement Income Security Act).
Each SPD should show you the procedure for filing a claim. Some plans may require you to file a claim (or get prior authorization, which is permission for treatment) before you can get medical treatment. Some plans have special rules for urgent (emergency) care. For other plans, you must turn in a claim for reimbursement (to get paid back the covered portion) after you pay for the care yourself.
Follow the steps outlined in your SPD when filing your claim. If you cannot find the steps, or don't understand them, call your plan administrator. You may also contact the Department of Labor's Employee Benefits Security Administration to help you understand your rights.
Your plan should state the time within which it must give you the decision on the claim you turn in. Be sure to look for this time limit in your SPD. When you submit a claim to your plan, note the date and keep track of the time as you wait for a decision. Some plans have different time periods depending on the nature of the benefit claim. For example, the claim for urgent care may be different and the claim may be filed before or after medical care is received. If you do not get a response from your plan within the stated time period, contact your plan administrator. See our document, Health Insurance and Financial Assistance for the Cancer Patient for more information.
What if my claim is denied?
Your plan may deny a claim for many reasons. For example, you may not have yet paid the amount of the yearly deductible. The requested treatment may be something the plan says is not covered or medically needed. Or you may not have filed enough information for the plan administrator to process the claim. Look for the reason and other information provided in the notice of denial so that you can figure out if you want to appeal the decision.
Before you appeal, you may want to take these steps:
- Ask for a full explanation of why the claim was denied.
- Review your health insurance plan's benefits.
- Contact your health plan administrator to find out more about the refusal.
- Ask the doctor to write a letter explaining or justifying what was done or what is being requested.
- Talk to your state insurance department or commission to learn more (Check the blue pages of your local phone book or visit the National Association of Insurance Commissioners on the Internet at: http://naic.org/state_web_map.)
You can then re-submit the claim with a copy of the denial letter and your doctor's explanation, along with any other written information that supports using the test or treatment that has been denied. Sometimes the test or service will only need to be "coded" differently to be paid.
When you are informed that your claim has been denied, your plan administrator also must tell you how to appeal your denied claim for a full and fair review. Your plan will tell you how long you have to file your appeal. Put this date on your calendar. When you appeal a denial, be sure to include any new information or evidence needed to support your claim, and get it to the right person and address within the time limit.
The plan's claims procedure should also tell you how long the plan has after you file to make a decision on your appeal. Make a note of this date, too.
You must be told when the decision is made on your appeal. If your claim is denied, you must be told the reason and the plan rules upon which the decision was based. This must be in writing and in language you can understand.
If you disagree with the final decision on your appeal or if your plan fails to make a timely decision, you have the right to file a lawsuit in court to get your benefits. The plan's explanation of denial should describe this right. You also may wish to get in touch with the Department of Labor's Employee Benefits Security Administration about your rights under ERISA. You might want to read more about claim denials in our document called Health Insurance and Financial Assistance for the Cancer Patient.
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