Getting Services Covered

Once you have insurance coverage, there are some things you can do to ensure that the services you request are covered.

Obtaining Pre-Certification. If you need to have an out- or in-patient medical procedure, surgery, or therapy; a visit to a new specialist; or the purchase of medical supplies or equipment, be sure to have the provider obtain pre-certification from your insurance company before providing the service. Most services providers have an insurance specialist that can assist you in obtaining the necessary documents to aid in insurance authorizations. Even if pre-certification is received, be aware that it is not a guarantee that the insurance company will pay in total or at all for the service. This should be explained in the pre-certification notice that you receive from the insurance company.

If the pre-certification request is denied, take the following steps:

Read the denial letter carefully and determine exactly why the service was denied.
Find out how to appeal the determination. The letter should give instructions on how to do this. If not, check with your policy booklet or call your insurance company. If you have a case manager, contact him or her.
Contact your employer's insurance benefits specialist. See if there is anything he or she can do to help you with the appeal.

When a claim is denied. When you receive an explanation of benefits (EOB) for a medical claim from the insurance company and your claim has been denied, check the explanation of services and the denial reason. The denial reason is often indicated by a code and a brief explanation. Before contacting the insurance company, verify the following:

Was the insurance policy in effect at the time of service?
Did the provider of services use the proper medical code and billing information? You can contact the provider to verify this.
Is there a pre-existing condition restriction attached to the policy? Are you still within that time period?
Is the service or procedure excluded from your policy? Check your booklet of benefit information.
If you use an HMO, is the provider of services within the network? Was a referral requested?
Did you request pre-certification for the service?
If both you and your spouse carry insurance, is there a problem with the coordination of benefits? For example In Ohio, insurance companies use the "birthday rule" to determine who pays first for children. The spouse with the first birthday in the calendar year has the primary plan. In divorce or separation situations, the parent with legal custody has the primary plan if the decree does not say who is responsible for the children's health care.

If after reviewing your claim you do not agree with the denial, try contacting the insurance company or, if applicable, your case manager. Ask if they can provide more information about the denial and if there is anything you can do to get the denial reversed. For example, some denials are due to lack of appropriate documentation from the provider, such as a statement of medical necessity. You may just have to get the information from the provider in order to get the claim approved and processed. Remember to document all types of contact with the insurance company (phone calls, letters, faxes, emails, etc.). Keep a record of the name and phone number of who you talk to, as well as what the person tells you. If you do not feel comfortable with the answers you are receiving, ask to speak to the person's supervisor. You can also contact your employer's health insurance benefits specialist for assistance.

If after talking to the insurance company you still do not agree with the denial, you have the right to appeal the decision. You must go through the insurance company's internal appeal process before taking any other action. Check your policy or benefits book for the company's appeal procedures, or contact the company by phone. Your appeal should be in writing and may require information from your doctor. If the denied claim decision is upheld, you may be given the option to proceed with your appeal for an independent review from an external source.