Insurance Basics: What to Do If Your Claim Is Not Approved

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While not every claim denial is so easily fixed, there are times a claim doesn’t get approved for reasons other than the service not being covered by a member’s health plan. Do you know what to do if a claim isn’t approved?

Find Out Your Next Steps
Do they have the wrong birth date listed for you? Is the address your doctor listed different from what we have on file? If the claim wasn’t approved because of an information error, reversing the denial may be fairly quick and easy. Call customer service at the number on your member ID card. You can give the customer advocate the right information to correct your file. If your provider’s office made the mistake, you can call the billing office to get the information corrected.

Understand the Appeals Process
There is a multi-step process in place that can help you if you think a claim has been denied in error. It is outlined in an insert included with your EOB. It is also explained in your benefit information.

Get Started
You’ll need to provide as much information as you can to support the claim. Medical review will require more information. For example, you may need:

  • A letter from your doctor explaining why the requested treatment should be approved
  • Patient notes from your treating physician on other care you have had for your condition
  • The results of other tests or procedures related to the request
  • Current medical articles or study results that support the treatment’s effectiveness
  • Your own letter explaining why you believe the treatment is needed

Hang in There
For things like wrong information, a quick correction can be made and the claim refiled for approval. But other reviews take time. A standard appeal takes about 30 days for review for getting care pre-approved. Other appeals may take up to 60 days. If your life or health could be at risk by waiting, you can ask for an urgent appeal. If you qualify, the review will be handled within 72 hours. You and your doctor will get a phone call from Blue Cross and Blue Shield of Texas explaining the decision and next steps.

Check Your EOB
You should always check your EOB to make sure your claim information is correct. Every EOB has instructions on what to do if a claim has been denied. You may get your EOB in the mail. If you are signed up for paperless communications, your EOB can be found in your Blue Access for Members online account.

Adapted from BCBSTX Blog post, Insurance Basics: What to Do If Your Claim Is Not Approved.  Read the full article.