What is an insurance claim?
When the insurance company receives notice of a claim, the first thing they do is confirm that the medical services received by the insured member are covered under that member’s health plan. Each medical service is assigned a procedure code that allows the insurance company to determine the exact services that were rendered. In some cases, a diagnosis code must also be included to inform the insurance company which medical condition led to the needs for the services for which a claim is being submitted. Procedural and diagnosis codes are commonly used in the medical profession and are the same for all insurance companies. If the insurance company determines that the claim received is for a covered service, they then review the plan member’s policy to see if there are any deductibles that must be met before the insurance company is liable for paying a portion of the claim. If there is a required deductible that has not been met, the insurance company will either request payment directly from the insured member or send the claim back to the physician and make them responsible for collecting the debt. If the insurance company bills the member directly, they will send compensation to the physician on behalf of the patient. In some cases, the service for which a claim has been submitted may have required pre-authorization from the insurance company. This means that the insurance company, under contract with the insured member, required that they be notified before this said medical procedure was performed. The reason they do this is because they want to verify that the procedure is the best or most efficient treatment available to the patient for their medical diagnosis. If a claim is submitted for a service that required pre-authorization, and this prior authorization was not received, the insurance company may deny payment of the claim or reduce the amount that they are willing to reimburse. Any claim that is denied by an insurance company may be appealed by the insured member, but this process is often futile. A dispute over a denied claim is typically caused by the health plan member not fully understanding the policy details or failing to follow proper procedures. 1 CommentLeave a comment |
|
What is an insurance claim?
In order for the insurance company to make reimbursement to plan members for covered medical expenses, they must be notified of the expense. This is done through an insurance claim form. When using physicians that are contracted with the health insurance company, claims are usually submitted through the doctor’s office or the medical group. Even some non-participating providers will handle claims processing on behalf of the patient, but they may be less familiar with the guidelines of the various insurance companies than a physician that works with them on a regular basis. Most people that use their regular participating physicians will never need to get involved in the claims process, but should receive copies of any correspondence between the physician and the insurer.
How do I appeal a denied health insurance claim most effectively? I have a number of claims that have been denied for different reasons, yet I don’t think they are correct in doing so. I was under the impression that these treatments were covered. I specifically checked with Coventry Insurance that chiropractic services were included in coverage, but when I filed to get them reimbursed, they denied them on the basis that those services were never included in the policy. I am pretty sure that they are wrong. The treatment I received was decompression therapy by the way. How would I go about this in the best way?
Comment by Tasha — June 21, 2009 @ 12:59 am