Is your denial intentional or just a billing error?
If you receive a denied claim, you should first look to see if it is because of a billing error. Re-read the paperwork or materials your health plan sent. These are called "Explanation of Benefits" (EOB) statements. Confirm that:
- You (or a covered dependent) made the visit to the doctor or medical provider.
- Make sure the covered person, the doctor, and the health insurance company are listed.
- Check to make sure the doctor or medical provider billed your health plan correctly:
- Are the charges correct? You may need to contact your doctor's billing staff to determine whether the codes used to bill your plan match the services you received.
- Is that date or dates of service correct?
If any of the details listed above are not correct, or you aren't sure what something on your Explanation of Benefits means, call your doctor or medical provider's billing office. Ask your provider to send you an itemized copy of your bill. (This is helpful in determining what was and was not paid for.) Ask them to explain your bill.
If the billing office tells you everything was billed correctly and you believe your health insurance company should have paid the bill, read "Billing Errors" for further information and instructions. You may also call our Consumer Advocacy consumer line at 1-888-877-4894. We'll help you decide if you need to file a complaint with our office, or file an appeal with your health insurance company or both.
Keep detailed records
Before you contact anyone, create a log to document:
o The type of contact you made, including the telephone number
o The date
o Who you talked to
o What was said
One reason to keep detailed records is that insurance companies may honor their mistakes.
If you received incorrect information from an insurance company's customer service representative, the company will verify that information. The company may honor that mistake - but only on past denials. It will not make the same decisions in the future once it provides the correct information.
If you think a billing error occurred, ask your doctor's office for details about the Current Procedural Terminology (CPT) or treatment code.
Sometimes valid disputes occur about treatment codes that doctors and other medical providers used to bill the health insurance company. Generally, health insurance exclusions don't refer to CPT codes. They refer to specific treatments and diagnoses. If a mistake was made, ask customer service to send you in writing how the correction will be made.
If you think the codes don't fairly represent the treatment you received, you can ask your doctor to re-bill the insurance company using the correct code and include your medical records for that visit.