| The research in the previous article examined HealthCare.gov claims denials and appeals for individual and family QHPs. From the research, it was evident that the issuer’s statistics are unconfirmed. Customers have less options for plan comparison and supervision since the federal government has not fully enforced transparency data reporting. The transparency data can show patterns in the occurrence and handling of unexpected medical expenditures under the No Surprises Act and whether the Mental Health Parity and Addiction Equity Act (MHPAEA) is being followed.
What if your health insurer denies your claim?
You can appeal a denied health insurance claim. You must understand and apply these rights given the Patient Protection and Affordable Care Act greatly strengthened them.
Read the refusal letter to understand why you were rejected and how to appeal. Your insurer must inform you of your right to appeal, provide clear instructions on how to submit your appeal, and notify you of any deadlines. State Consumer Assistance programs must be disclosed.
Your insurance company may deny your claim if the service is not medically necessary, the treatment is ineffective, or you do not meet your health plan’s benefit criteria. Prior authorization does not guarantee claim payment, so read the fine print and fully understand your contract.
If your initial appeal is denied, you’ll be told how to appeal again. Work with your providers to avoid medical bills going to collectors while you appeal.
Requesting a care denial review will not cancel or increase health insurance. Thus, if your claim is denied, you should appeal following your insurer’s standards. |
