Insurance claims are common. An analysis by the Kaiser Family Foundation found that in 2017 health insurance market insurers rejected an average of 18% of claims on online providers. When your claim is rejected, you may have to pay your therapist out of pocket. This unexpected account can make it difficult to provide more treatment sessions, possibly preventing your progress in treatment. While denying the claim can be frustrating, it is not the last word on the subject.
Recourse to a request begins with an understanding of the reason for the refusal. Once you understand the situation, you can turn to your insurer internally. If the insurer still fails to pay, you can request an external review.
Common claims claims are not accepted
Before submitting an appeal, you need to know if your application was rejected or rejected. A rejected claim is an insurer that has never been processed, usually due to errors in the claim (such as a wrong name). A rejected claim is a claim that the insurer has processed and rejected to cover, usually because the insurer believes that the services included in the claim are not covered.
Common reasons for rejecting or refusing insurance claims include:
- The claim includes an account for uncovered services. This can happen if your coverage only starts when you hit the discount or if you do not have coverage for the specific services you received.
- You should seek prior authorization for care. This is often the case when you see an expert.
- Your provider has sent the claim to the wrong insurer. If you have recently changed your insurance plans, correcting this issue could be as simple as re-submitting the claim to the right insurer.
- Account transfer errors. For example, your birthday may be incorrect or your name may be misspelled.
- The provider that submitted the account used an incorrect CPT code (this informs the insurers about the type of service you received).
- You used an off-line provider. If you change your insurance plans, a mental health professional who was online for your old plan may be out of network for the new plan.
Insurers are urged to notify you in advance if they have denied your claim. This notice will usually explain why the insurance company chose not to pay. What counts as a "reasonable amount of time" depends on the type of claim you have filed.
- Insurers must notify you within 72 hours if you require prior authorization for emergency care.
- Insurers must notify you within 15 days if they refuse prior approval for non-emergency treatment.
- Insurers can take up to 30 days to tell you about the services you have already received.
Creation of an internal appeal
If your claim is rejected, it means it has never been processed. You or your mental health provider must resubmit. This creates a new requirement. It's not the same as an appeal.
If the claim is rejected, you must file an internal appeal. Consult your Explanation of Benefits (EOB) to appeal the refusal. An EOB is a document that describes each service in the claim. It also explains why the claim (or specific services under the claim) was rejected. Most insurers use specific codes to indicate why a claim was rejected, and many EOB documents contain a key to these codes. If the EOB contains codes but no key, contact your insurer to request a key.
Fill out the forms your insurer requires for an appeal. If the insurer does not require specific forms, you can send a copy. Your letter should include:
- Your name, claim number, and health insurance ID.
- Information about the rejected claim, such as the date, billing code, and services you received.
- The reason for denying the claim, as well as the reason why you think the claim should be reconsidered.
- Any additional information you would like to add to the claim. For example, if you received prior approval for a rejected claim, note it.
The review should be short and easy to read without unnecessary information or claims. Take note of a few paragraphs at most.
You have 180 days from the date of refusal to appeal. If you appeal for services that you have not yet received, your insurer must notify you of its decision within 30 days of receiving the appeal. If the denial concerns services you have already received, insurers have up to 60 days to respond to your appeal.
Know your rights under the MHPAEA
The MHPAEA Equity and Mental Health Equity Act requires insurers to provide similar coverage for mental health and physical health conditions. For example, if an insurer charges a $ 20 copay for a visit to a doctor, you generally cannot charge a $ 80 copay for a visit to a mental health professional. Also, it may not impose restrictions on mental health coverage, but it does not apply to physical health conditions, such as requiring prior authorization or extending coverage only after you obtain a discount.
Despite this law, some insurers may illegally reject mental health claims. Referral to the MHPAEA in your appeal may make your claim more likely to be accepted at the new submission.
Get external review
If the insurer supports his refusal, you are entitled to an external review. In some states, the federal government's Department of Health and Human Services will select a reviewer to oversee the process. This critic is not an employee of the health insurer.
If the federal government does not oversee the process in your state, your insurer will likely deal with an independent third-party judge. Some states offer alternative external review options that extend more rights to consumers, so check state regulations before filing your appeal.
To begin the external review process, issue your request for an external review within four months of receiving the refusal. The application must be in writing. Include all the information that was included in your initial review of the external review. If new information is available, make sure you include it as well.
In standard external reviews, you will reach a final decision within 45 days. If you call for a refusal of emergency care services, you can request an external review before the internal review process is complete. These rapid revisions must be completed within 72 hours.
If the external review overturns your insurer's decision, your insurer is required to comply with its decision and to cover the claim. If the reviewer supports the denial, you will be responsible for paying the claim. This means that you will need to talk to your mental health provider about payment settings. In some cases, a mental health professional may be willing to work out an extended payment plan.
Many states offer assistance in understanding and resorting to unacceptable claims. To find the consumer help program in your area, click here.
- External Review. (n.d.). Retrieved from https://www.healthcare.gov/appeal-insurance-company-decision/external-review
- Gerber, J. (n.d.). What is the difference between rejected claims and rejected claims? Retrieved from https://info.medcorinc.com/blog/what-is-the-difference-between-denied- claims-and-rejected- claims
- Glover, L. (2016, March 11). 5 Reasons Why Your Health Insurance Plan Will Deny Your Medical Claim. Retrieved from https://www.nerdwallet.com/blog/health/5-reasons-health-insurance-plan-deny-medical-bill
- Internal appeals. (n.d.). Retrieved from https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals
- The Mental Health and Volunteerism Act (MHPAEA). (2016, October 27). Retrieved from https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html
- Pollitz, K., Cox, C. & Fehr, R. (2019, February 25). Challenging claims and appeals to ACA's market plans. Retrieved from https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plan
- Deferment of a revised claim. (n.d.). Retrieved from https://therabill.zendesk.com/hc/en-us/articles/217247143-Resubmission-versus-Corrected-Claim
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