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Our Mission is to save the lives of children and young adults who
are genetically predisposed or otherwise susceptible to sudden death
due to cardiac arrhythmias and to provide education and support to
families and the medical community who are dealing with these disorders.
The SADS Foundation is dedicated to providing
information, assistance & hope.
[MORE
INFO]
site updated October 22, 2007
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Health Insurance Tips: Handling A Claim Denial or Refusal to Cover a Prescribed Service
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| It is not unusual for particular claims to be denied or for insurers to say they will not cover a test, procedure, or service that your doctor orders. If this occurs it is important to have a working relationship with a customer service representative or case manager at your insurance company with whom the situation can be discussed. This is your insurance—even if your employer pays for it—and you are the best person to get your company to pay for needed tests or services. Your doctor can help with a letter and/or recoding the claim, but you are still the best one to put it all together and get it done. Many companies (those that make ICDs or AEDs, for example) have staff the help you get coverage for their products but it is still just a
A first step should be to resubmit the claim, sent with a copy of the denial letter. It may be necessary for the patient's doctor to explain or justify what has been done or is being requested. Sometimes the test or service only will need to be "coded" differently. If questioning or challenging the denial in these ways is not successful, then you may need to:
- Postpone payment until the matter is resolved.
- Resubmit the claim a third time and request a review.
- Ask to speak with a supervisor who may have authority to reverse a decision.
- Formally appeal the denial in writing, explaining why you think the claim should be paid. SADS may be able to help with this.
- Request a written response.
- Keep all originals of correspondence in your possession
- Keep a record of dates, names, and conversations you have about the denial.
- Seek help from the consumer services division of your state insurance department or commission.
- Be persistent in trying to resolve the matter.
- Consider legal action.
SADS will continue to provide help with health insurance issues. We are developing materials for the three issues we hear about most: (1) getting insurance coverage (especially young adults), (2) coverage for genetic testing and (3) coverage for devices. If you would like to help—or tell us about your experience—please let Alice know (alice@sads.org). |
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