Few things are more stressful than receiving a denial letter from your health insurance company, especially when you’re counting on that coverage for medical care. If your health insurance claim has been denied in South Dakota, it’s important to remember that you have rights and options. Acting quickly and understanding the process can make all the difference in getting the care and coverage you deserve.
Why Was My Health Insurance Claim Denied?
Insurance companies often deny claims for various reasons. Common explanations include:
- The service was not deemed medically necessary.
- The treatment is considered experimental or not covered by your plan.
- There was a paperwork error, such as missing information or incorrect billing codes.
- The provider was out-of-network.
- The claim was submitted outside the required timeframe.
It’s important to carefully review the explanation of benefits (EOB) or denial letter you receive. This document outlines the reason for the denial and provides instructions for appealing the decision.
Step 1: Review Your Policy and the Denial
Before taking further action, take the time to review your insurance policy. Make sure you understand what is and isn’t covered. Compare the denial reason with the language in your policy. Sometimes denials are the result of a simple mistake that can be resolved with clarification or additional documentation.
You should also double-check for:
- Clerical errors (wrong patient info, wrong codes)
- Proof of pre-authorization, if required
- Provider network status
Step 2: Contact the Insurance Company
Sometimes, a phone call to the insurance company’s claims department can clear up misunderstandings. When you call:
- Take detailed notes, including the date, the representative’s name, and a record of what was discussed.
- Request specifics about why the claim was denied and what evidence could support an appeal.
- Request copies of any necessary forms or documentation to initiate the appeal.
Step 3: File an Internal Appeal
Under both South Dakota law and the federal Affordable Care Act, you have the right to appeal a denied health insurance claim. The first step is to file an internal appeal with the insurance company. This means asking the insurer to reconsider the claim.
To do this:
- Submit a written appeal within the time limit specified in your denial letter
- Include any supporting documents, such as medical records, doctor’s letters explaining why the service was necessary, or proof that the provider was in-network.
- Keep copies of everything you send.
Step 4: Consider an External Review
If your internal appeal is denied, you may be entitled to request an independent external review. This process involves an outside organization, one not connected to your insurance company, evaluating the claim. The external reviewer’s decision is typically binding on the insurance company.
Step 5: Speak With an Attorney
If you’re struggling with a complex or unfair claim denial, it’s wise to consult an experienced attorney who specializes in insurance claim disputes. Insurance companies have teams of lawyers reviewing claims. You deserve someone on your side who understands the law and can advocate for your rights.
An attorney can:
- Help you navigate the appeals process.
- Ensure you meet critical deadlines.
- Collect and present the strongest possible evidence.
- Represent you in court if needed.
Abourezk Law Firm Is Here to Help. Contact Us Today
At Abourezk Law Firm, we understand how overwhelming it can feel to face a health insurance claim denial while dealing with medical issues. Our team has years of experience standing up to insurance companies and fighting for clients’ rights.
If your health insurance claim was denied, don’t give up hope. Contact us today for a consultation. We can review your case, explain your options, and help you work toward the coverage and care you need.