If you have health insurance and a claim is denied, you can take the following steps to try and resolve the problem:
- Keep copies of all correspondence (such as letters and e-mails) with the insurance company about the claim. Note the claim number and policy or procedure code on all correspondence. Also note the name of any customer service or claims representative you speak with on the telephone.
- Call the insurance company to find out why the claim was denied. If it is still unclear, study the explanation of benefits form. In some cases, the denial may be the result of a claim being improperly recorded, such as a service being mistakenly omitted.
- Check the facts. Review the policy to make sure that pre-certification, authorization and other procedures required by the insurer were followed. For example, claims for prosthetic bras, implants and wigs require a copy of both the prescription and the bill.
- Ask your health care provider for help if fees, charges or procedures are questioned. Most health care providers and their staff are used to working with insurance companies and can help answer questions. Ask the health care provider to write a letter to the insurance company recording and/or justifying the charges or procedures, and be sure to keep a copy.
- If the claim is denied because the insurance company says that a treatment is experimental or under study, ask your health care provider to help. If he/she can give the insurance company evidence that the scientific literature supports the use of a certain therapy for your treatment, then it cannot technically be labeled as experimental. Your provider can get peer reviewed studies or reports and support letters from other oncologists using the same procedure. National patient support organizations can also help.
- Ask for a formal review of the denied claim. Often, claims that first were denied are paid in later reviews. If this fails, ask for an appeal of the review using outside cancer experts to review the medical records and claim.
If these steps fail to get payment for a claim that you and your health care providers believe is justified, a final option would be to contact a lawyer. National patient support organizations can help identify lawyers in each state who specialize in cancer-related insurance issues. The Patient Advocate Foundation can try and help resolve problems and offer other help with insurance issues involving insurers, employers and/or creditors.
Updated 02/02/09
