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Getting on Top of Insurance Claims: Things to Keep in Mind So Your Claims Won’t Get Denied

November 5, 2018 | By Ana Elliot

Health insurance is something that can provide just as much worry as comfort. When it works for us it works well, but other times it leaves us vulnerable financially when we are at our most vulnerable. Sometimes, it’s hard to know what our insurance will cover and when it will have our back. If you have ever had a procedure or treatment and wondered if your insurance would cover it, then this article is for you. Here are a list of things you should double-check to make sure your insurance is covering you as much as it can.

In Network Providers

One of the things you should check any time you are getting a procedure or start going to a new doctor’s office is whether or not that provider/doctor is in your insurance’s network. Most insurance companies do not cover out of network and that could leave you in a bind. Asking what insurance the office accepts should let you know ahead of time, but it is also a good idea to speak to your insurance if you are unsure.

Make Sure Your Doctor Gets Pre-Authorization

For some procedures, like MRIs or CT scans, pre-authorization is required. This is something that, if your doctor’s office doesn’t automatically do, you can ask them to do. Insurance companies will often deny coverage on a procedure that they would have covered, had you gotten pre-authorization. It’s one of those nitpicky bureaucratic things you have to stay on top of!

Don’t File Late

Another one of those nitpicky bureaucratic pitfalls to keep in mind is filing a claim on time. Generally, you have 90 days from when the procedure happened to file with your insurance. If you are late, you will often be denied. As important as it is to treat your illness in a timely manner, so too is it important to take care of the insurance on time!

Get Your Referrals in Order

Some insurance companies require referrals from your in network primary care physician before they will let you go see specialists or have a procedure from a different provider. While getting a referral might feel like a chore and often times doctors’ offices are backlogged with referral requests, it’s important you take care of this before you move forward.

Errors in the Details

Another issue that causes denials but that can easily be avoided is minor errors on documents submitted. If a name or date is incorrect, the insurance will deny it. Luckily, you can submit (as long as you do it within 90 days!) and solve the problem. It's easier though to make sure that these errors don’t exist in the first place. The faster it is taken care of, the less you have to worry about it!

Uncovered Procedures

Lastly, something to keep in mind as you go forward is whether or not the procedure or treatment you are looking for is covered by your insurance. Depending on your insurance’s stance on pre-existing conditions, you might find some of your most necessary treatment is denied. Other times, the treatment might be something they deem “medically unnecessary” which can mean no coverage. You might even need to look for other options to pay, such as an installment loan. This last point is often something you can’t help and, at the end of the day, the treatment might be something you need anyway.

We hope this has been helpful, either for understanding why an insurance company might deny a claim or to help you make sure your claim goes through with no issues! It might even be something you use as you pick out a new insurance policy. Either way, be happy and healthy!