How to Appeal an Insurance Company’s Decision

 In Appeals, Personal Injury

Sometimes insurance companies fail to pay medical claims. Fortunately, in these situations, there are steps that a person can take to appeal the insurance company’s decision. Among other options, the Affordable Care Act provides individuals the right to disagree by filing an appeal. If you decide to appeal, an insurance company will review your case and make a decision. In these situations, a seasoned accident attorney can prove essential in navigating the various issues that arise and making sure that you obtain the compensation that you deserve.

If a health plan denies your insurance claim for medical services, you have the right to learn why your claim has been rejected. As a result, your insurer must detail its decision to reject your claim in writing. The most common reason why health plan carriers deny insurance claims is if the billed service is not considered to be medically necessary. Other reasons for rejecting a claim include if the proposed treatment has been proven to not be effective, if the treatment is largely experimental, or if a service is billed or coded incorrectly.

The Right to an Appeal

Most health insurance contracts state that you have a right to appeal in case your appeal is denied. You are also often granted the right to a review by an independent third party if your appeal is denied. Your insurance company also must explain how you can initiate the appeal process because there are often strict time frames required for appealing a claim. A knowledgeable attorney can also review your health plan prior to an appeal to determine what health services are covered.

Internal Review

While the appeal process can vary significantly between health insurance plans, nearly all appeals begin with a request for reconsideration. Some health insurance plans, however, proceed directly to the internal review. During the period of internal review, the insurance company conducts a review of its decision, which has the potential to take up to 60 days. The staff (often a medical director) who reviews this decision will not have had any role in rejecting your insurance claim.

External Reviews

If an internal review still denies your application, you have the right to an external review. This part of the process is often complicated, which means the assistance of an experienced attorney who understands the process can be particularly helpful. Expert medical consultants will likely be the professionals responsible for conducting the external review. The minimum requirements for an external review in accordance with federal law are that the medical services for which a person is requesting payment must meet certain requirements including that a person’s benefits for the appropriate category of medical services must not have exceeded their limit. While the external review process often takes 60 days to resolve, sometimes it takes less. If the external review sides with the patient, the insurance company must pay the claim.

Talk to a Skilled Accident Attorney Today

Navigating the appeal process for a denied insurance claim can be complicated, which is why you should not hesitate to obtain the assistance of a seasoned attorney. Speak with the legal counsel at Ferrara Law today for the assistance you need.

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