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.