There are a lot of people that offer this service for a fee but you can also learn how to do it yourself or start a business from it. When you visit your doctor, you are handed some forms to fill. These forms would request for your health insurance details. After filing the forms, you hand them over to the receptionist along with your health insurance card and then the health insurance claims process begins.

Health insurance claims processing involves three parties; you, your healthcare service provider and your insurance provider. It is a means through which your healthcare provider gets its payment from the insurance company for services rendered.

Usually, in the policy, the services which the policy would cover would usually be stated. Therefore, the first step to health insurance claims processing is finding out what your health insurance policy pays for and what it doesn’t. If you go for a service that your policy doesn’t cover, your claims would be rejected and you may have to pay for it yourself. So, you must carefully read and understand your policy and asks the insurance agent or company to provide further clarification for anything you find confusing.

Some health insurance plans also involves co-paying. This means that you pay some amount of the value of your bill while the insurance company pays for the rest. For instance, if your bill is $500, you may be required to pay $125 while the insurance company pays the balance. But like I said, it all boils down to what is written in the health insurance policy that you signed agreed to.

Upon payment of your own portion of the bill, the health service provider forwards your bill to the Claims Processing Center. Upon receipt of the bill, the processing center gathers all relevant information about you-the patient. It would also compare the approved services in your health insurance policy documents with the service received to find out if it is covered.

If it is discovered, then your insurance company takes responsibility for payment of the bills. This is basically how health insurance works and the process is supposed to be a smooth one only that it is not. A lot of times, health insurance claims get denied by the insurance company and you get stuck with an unplanned debt which you have to start thinking of how to pay off. Let’s look at some of the reasons why health insurance claims get denied-:

5 Reasons Why Health Insurance Claims Get Denied

a. Not receiving prior authorization

To be on the safe side always, you have to first communicate with your insurance provider before you present yourself to your doctor for treatment. Once you have been diagnosed, you should also receive approval before you commence treatment treatments. Encourage your doctor to speak with the insurance company and inform them of the procedures and medications that would help to rule out the issue of non-authorization.

b. Non-Coverage

This happens when the type of treatment you received was not covered by your insurance policy. A common example is plastic/cosmetic surgery. When you undergo cosmetic surgery or get treated for complications arising with cosmetic surgery, your insurance company might refuse to pay for it because it was not stated in your insurance policy.

c. Time Lag

Time is also a very important factor in health insurance claims processing. Ensure that all claims processing are done within specified time frame in the insurance policy. You may not be able to file claims in 2014 for a treatment received in 2011. Hence, you must make sure that your claims are filed in processed within the shortest time possible.

d. Unnecessary medical procedure

If the insurance company feels that you received treatments for conditions that it deemed unnecessary, it may decide to reject your claims. For instance, if you decide to go for teeth scaling and polishing and your insurance policy doesn’t specifically cover it, the insurance company may decide not to pay you, claiming that it wasn’t a health or life threatening condition.

e. Administrative Errors

Medicals claims can also be rejected as a result of clerical errors and improper claims filing. Although, this is easy to fix; all you need to do is to fix the errors and file the claims again. Note however, that everything must be done as fast as possible and within a strict time frame.

So what should you do when your health insurance claims get denied?

5 Steps to Take When Your Health Insurance Claim Gets Denied

1. Understand why your claim was denied

First, you have to understand why your application was rejected. As soon as you receive your statement of benefits, talk to the insurance company or your healthcare provider; don’t panic at this stage, a lot of people get their claims rejected but with the right process, you can resolve the situation.

2. Ask for expert advice and assistance

Next, you should seek for assistance from professionals. Your healthcare provider could assist you with reversing your denial. You can also find help with hospital social workers who are employed or attached to a hospital to assist patients with such problems.

The doctor who treated you is also very useful in this regard. The doctor can assist you with presenting your case to the insurance company by providing more information that would guide the insurance company in making its decision.

3. Re-apply

After you get a rejection, don’t give up immediately. You should gather more information and file your claims again. You may be able to get an approval for an application that was initially rejected if you reapply. And the thing is that by reapplying, you are automatically increasing your chances of getting an approval.

4. Keep Adequate Records

When dealing with your insurance company, ensure that you keep a record of every correspondence with them. This is known as a paper trail and is very useful especially if you have to seek a redress in court.

5. Understand the system better

Experience isn’t complete until you have learnt something from it. A denied health insurance claim can be very frustrating but there are still useful lessons to be learnt from it; you would be able to understand the system better and know what avoid and how to go about it in the future so that you don’t get denied.

Ajaero Tony Martins