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Why Was My HMO Claim Denied?

If you file a claim with your health insurance company and it is denied, it can be extremely frustrating. On a positive note, you have the right to appeal that denial, and with the right representation, you will probably win. If your health maintenance organization (HMO) claim has been denied, there are actions we can help you take.

At Dawson & Rosenthal, P.C., our goal is to see that our clients’ medical bills are taken care of by their insurance companies. Reach out to us today for a free consultation. We are ready to advocate on your behalf.

Reasons a Claim Might Be Denied

Often, the insurance company denies a healthcare claim because of an error or oversight in its submission. This denial could mean any of the following were overlooked or handled incorrectly:

  • Coding errors
  • Lack of information
  • Oversights
  • Misunderstanding

If you file a claim and it is denied, the insurance company is required to send you a breakdown of what they covered and what was denied, and how much was actually paid. If your claim is denied because your insurance company did not cover a medical procedure, you may have to provide proof that it was medically necessary.

Common Reasons Healthcare Insurance Claims are Denied

Health insurance companies do not want to pay out any money. Often, they will go out of their way to deny coverage when claims are filed. Listed below are some of the common reasons that insurance claims are rejected:

  • Using an out-of-network provider or facility
  • The insurer did not receive adequate information
  • More information must be provided
  • The denial occurred because the health plan did not approve it as a medical necessity.
  • Typos and clerical errors

Appealing an Insurance Company’s Claim Denial

Winning an appeal against an insurance company after it has denied your claim may be easier than you would imagine. Some denials can be overturned relatively painlessly. Since they do happen because of oversights, missing information, coding issues, and mix-ups, they can often be resolved quickly.

Steps You Should Take Following an Insurance Claim Denial

If your health insurance claim is denied, there are steps you must take. Knowing how to handle an insurance claim denial can be invaluable. Listed below are some steps you should take if your claim is denied:

  1. To begin with, contact the insurance company to find out why you were denied. Note who you speak with, the reference number of the call, and the time and date, and set a reminder to contact the insurance company to follow up in 30 days.
  2. Review your policy. Knowing what your plan covers and how co-pays are managed can be helpful. If you cannot find a copy of your policy, ask your insurance company or your place of employment for a copy.
  3. One of the first things you should do is determine if there is a deadline for appealing the claim denial. Taking prompt action can nearly always help you avoid a deadline-related problem.
  4. Assemble the necessary documents. For instance, if your health insurance denies a claim that your doctor feels is medically necessary for you, make sure you have documents backing that ascertain up.
  5. Compose a succinct appeal letter. Include all identifying information, the dates that services were provided, and the claim number. Your letter should include the following:
  • Early in the letter, state why you are writing, and that is to appeal a claim denial.
  • Explain the reasons you believe your medical expenses should be covered by your insurance policy.
  • Close by demanding a specific amount of reimbursement and including any documents that support your case.
  • Limit emotional discussion. The fewer words you include, the more likely someone will read it.
  1. Do not just let it go. If you do not hear from the insurance company about your appeal, call again. After you write the letter, give them a week to receive it, and then follow up to make sure it was received.
  2. Hire an attorney with Dawson & Rosenthal, P.C. Our team understands how to navigate denied insurance claims and will ensure your rights are protected.

We Can Help With Your HMO Claim Denial

If your claim was denied, we can help. Reach out today to a health insurance bad faith lawyer in San Diego at Dawson & Rosenthal, P.C., for a free consultation. We will review your case and discuss what we can do for you. Call us today at (866) 937-3820 or fill out our online form to get in touch.