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Have you ever had a health insurance claim denied unexpectedly or had a claim delayed for weeks with no explanation? Due to the confusing nature of medical billing and insurance claims, people often don’t dig deeper into such issues despite their frustration. However, often a simple mistake is the root of a denied or delayed claim and there may be an easy solution.

Problem: Your claim is denied or delayed because you did not provide your current health plan information during your health care visit.

Solution: Always make sure you have your current health plan information with you, and remember to give your provider updated information when you have a plan change. When you receive a new health insurance card, dispose of old cards so you won’t accidentally use the wrong one. If you lose your card, contact HR to get a new one. If a claim is denied, check if this was the problem.

Problem: The insurance company is unsure if your injury is work-related, and thus spends months investigating.

If you have a work-related injury, it is important that you alert your doctor during the visit that it happened at work. In addition, even if it was not work-related, always promptly answer any questions your doctor or insurer has about your claim. A simple returned phone call can save you weeks or months in delay.

Problem: Your health care provider coded a claim wrong (such as attributing a claim for circumcision to the mother, not the newborn).

Solution: If your claim gets denied unexpectedly, call the insurance company and check if it was coded correctly. If not, ask your provider to fix the error and resubmit your claim. In addition, know how different treatments are covered under your plan. For example, certain therapies may be covered only if “medically necessary” – so make sure your provider indicates it as such when submitting your claim.

Problem: There may be confusion if your dependents are covered under two plans.

Solution: If your dependents are covered under both your and your spouse’s plan, you need to find out which plan is the primary provider. This is typically the plan of the parent whose birthday comes first in a calendar year – but double check with your insurer. Otherwise, claims may be delayed while the two insurance companies argue over who is responsible to pay.

Problem: You misunderstand your benefits, resulting in confusion when your claim is denied.

Solution: Learn as much as you can about your health plan! Read the plan documents and tap into any other resources available, such as the insurance company’s website. If you have questions, ask HR or your insurance company before you see the doctor, to make sure you understand your coverage. If your doctor recommends a treatment, check first if it is covered and what amount you are responsible to pay.

Posted 7:35 AM  View Comments

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