This is a guest post written by my partner, Avrom Fox, MSW.
Your insurance claim has been filed. A number of weeks pass and you receive an EOB statement (EOB = explanation of benefits) from your insurance company showing what you may owe. You continue to wait, and then you receive a bill from a physician, a hospital, or any medical service provider, showing a balance due. The bill will generally specify the service performed, the amount the insurance paid, and then your balance.
If you do not agree with this balance, check the policy to make sure the service is covered in your plan. If you are in a group, you may want to contact and discuss the matter with your HR department. If you have called the provider and they confirm that you have a balance, you now have a legal right to appeal the claim to your insurance company. Many people fear engaging in this process, because they believe it is easier to pay than to fight. However, you have a legal right and you should appeal.
What do you need to do?
1. Write a letter not to exceed one page and explain why you believe the denied claim should be paid. Include your ID number, the claim number, the health provider, and the date of service;
2. Keep records of all communication with your insurance company, whether by phone or in writing.
3. If your initial appeal letter is rejected, don’t give up. Go to the second level of appeal. This is called an External Review. The insurance company must reconsider your claim using professionals who are not connected to your insurance company. If these professionals agree that your claim is valid, it must be paid.
4. The most important resource is your physician or health care provider. You must advise them of your appeal and seek their support. This may require the physician to write a letter explaining why a treatment in question is necessary.
If you fail the external review, don’t give up. Keep trying. You should also consider the service of a trained patient advocate who knows how to navigate the complexities of the health insurance system.
