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What You Need to Know about Making a Claim on Your Health Insurance


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When you need to make a claim on your health insurance, it’s important to remember a few things.

Read your policy.
If possible, read your policy before you go for care in the first place. You may need to get permission (a referral) to see a specialist or to get a lab test. You might be restricted to a network of doctors or hospitals. Going out of network might mean you will pay more or that the plan will deny your claim. You might need to submit the claim within a certain number of days following the service in order for it to be paid. Reading your policy is important to understanding what coverage you have and how to use that coverage. You may want to gather a list of questions to ask your insurer or healthcare provider before beginning treatment so you can make sure that your recommended treatments will be covered by your health insurance, and understand which services may not be covered.

Keep good records.
Include copies of all bills and correspondence. Ask for names, addresses, and phone numbers of people you talk to, and note the dates of your conversations. It’s a good idea to keep all original bills for followup purposes, unless your insurance carrier is one of the few that insists you send the originals. In that case, you should keep very good copies for your records. It may be helpful to ask a friend or family member to help keep your records organized and ensure that you have the copies you need, at least while you’re in active treatment.

Because of health reform, most insurance appeals are now standardized under federal law.

Submit your claims on time and in the right order.
Your insurer will pay some bills directly to the appropriate parties if you request that on the claim form. Other bills you must pay yourself and then send copies of the bills to your insurer who then reimburses you directly. Most insurance companies have a time limit for submitting claims. It could be one year from the date of service or by the end of the calendar year. Make sure you know what your policy defines as the time limit. If you have more than one policy, you must send the right bills to the right company in the right order. Remember that your insurance is always primary; your spouse’s is secondary.

If a claim is denied, appeal it.
Always ask if the payment was denied due to a billing or clerical error first. Then send the claim back again and again if necessary. Gather health records and other documents relevant to your claim, and ask your doctor to help make your case. Keep records of all your correspondence: who you talked to, what you talked about, and when you talked to them. And again, be aware of any time deadlines that might apply. Sometimes you can only appeal a denial within a certain number of days following the decision, and deadlines may vary by insurer, by state, and at each level of appeal.

Because of health reform, most insurance appeals are now standardized under federal law. First, you will want to find out if your plan is “grandfathered” and therefore exempt from the new appeals process. Grandfathered plans are plans that were in place when the Affordable Care Act passed (March 23, 2010) and have not made significant changes to benefits or cost sharing since then. You can check with your insurer if you need to know whether your plan is grandfathered. Even if your plan is not subject to these new protections, you should check with your health plan, your state insurance department, or your employer to see if you have similar rights.

If you have these new appeal rights, you must first appeal to your health plan through an internal appeal, which means your plan will have to review its decision. You have the right to learn why your claim was denied, to see your file and materials that supported the denial, and to present evidence as part of your appeal. If your appeal is denied, check with your insurer and your state to determine whether you have the right to additional internal appeals. If not, you will have the right to an external appeal, no matter whether your plan is regulated by state or federal law. An external appeal will be reviewed by an independent review organization; these panels overturn plan denials about half of the time, so it’s worth it to hang in there. Contact your state insurance commissioner for more information about your appeal rights.

You have the right to learn why your claim was denied, to see your file and materials that supported the denial, and to present evidence as part of your appeal.

You also have appeal rights if you have insurance through Medicare. These rights give you five levels of potential appeals. First, you can request a redetermination – a review of your coverage denial – by filing Form CMS-20027 within 120 days. If this is denied, you can ask for a reconsideration, which is an independent review of your claim. This must be requested within 180 days of your redetermination request being denied. Next, if your claim is worth at least $130 and your reconsideration is denied, you may request a hearing by an administrative law judge (ALJ). Fourth, if the ALJ denies your claim, you may appeal within 60 days to the Medicare Appeals Council for review. Finally, if the Appeals Council denies your appeal and your claim is worth more than $1,300, you may appeal to a U.S. District Court. For more information on the Medicare appeals process, see hhs.gov/omha.

If you have Medicaid coverage, you have the right to a fair hearing before a state agency if your request for services is turned down or is not acted upon within a reasonable timeframe. If you belong to a Medicaid-participating managed care plan, you have the right to internally appeal a plan action, such as when your Medicaid plan refuses to pay for a healthcare service or reduces the amount of care they will authorize for you. Additionally, you may file an internal grievance for other types of problems with your Medicaid plan, such as poor quality care. You may also go to federal court by filing suit against the state Medicaid program.

Understand your coverage for experimental therapies and clinical trials.
Sometimes an insurer will deny coverage for care they say is experimental. Insurers generally regard drugs, devices, and courses of treatment still under study as experimental. In other cases, some people may want to enroll in a clinical trial. A cancer clinical trial is a study designed to compare the efficacy of a particular drug with the standard method of treatment. Medicare and some state laws now mandate coverage for routine patient costs associated with cancer clinical trials, and beginning in 2014, all group health plans and individual policies will be required to cover these costs. If your plan denies coverage for care related to a clinical trial, appeal the denial, following the external review procedures outlined in this article.

Know where to turn for more information.
It’s always best to ask your insurance company or your employer for help answering your questions or solving your insurance problems. If this doesn’t work, though, there are other resources.

Most states now have Consumer Assistance Programs, or CAPs, to help you with your problems related to private health insurance. Your state CAP can help you answer your insurance questions, find coverage options, and appeal denied health insurance claims in any kind of private health insurance – whether a policy you purchased on your own or coverage provided through an employer. For a list of state CAPs, see healthcare.gov/law/features/rights/consumer-assistance-program.

Your state insurance commissioner can also be an important resource. They can help you understand state laws and programs and direct you to other sources of assistance. They also can help you figure out whether your plan is one that they regulate.

The United States Department of Labor Employee Benefits Security Administration (EBSA) regulates group health plans sponsored by employers in the private sector. EBSA’s website and publications provide important information about protecting personal rights to healthcare coverage. Visit dol.gov/ebsa/hbec.html or call EBSA’s Employee and Employer Hotline at (866) 444-3272 for free copies of their consumer health publications.

EBSA also makes available a wealth of information on the Affordable Care Act, with particular emphasis on issues that fall within the Department of Labor’s jurisdiction. Many of their materials are more technical than consumer-oriented. You can find these materials at dol.gov/ebsa/consumer_info_health.html.

The Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services regulates HIPAA and COBRA compliance by group health plans sponsored by state and local governments. In addition, it runs the Medicare program, partners with the states on the Medicaid program, and provides federal oversight and guidance on the insurance reforms and insurance exchanges included in the Affordable Care Act. For more information, contact CMS at (877) 267-2323 or visit cms.gov.

Your State Health Insurance Assistance Program, or SHIP, can also help you with questions about Medicare, Medicare Advantage, and Medigap coverage. You can find contact information for your state’s SHIP program at ShipTalk.org.

For very complicated problems, you may need to consult a lawyer or another expert for professional advice and help. Or you may want to ask a friend to help you make some of these calls, gather information, and keep track of the paperwork. If a professional is needed, however, make sure he or she has expertise in health insurance (not all lawyers or accountants do). Health insurance can be complicated and frustrating, but you are not alone. Be persistent and take advantage of the help that is available for you.

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Reprinted with permission from What Cancer Survivors Need to Know About Health Insurance, seventh edition, a publication of the National Coalition for Cancer Survivorship, copyright © 2012 by the National Coalition for Cancer Survivorship, canceradvocacy.org.

This article was published in Coping® with Cancer magazine, March/April 2013.