You receive a medical bill for services you believe should be covered under your health plan. Your insurer won’t pre-authorize a procedure. Your doctor is dropped from your insurance company’s preferred provider list. These policyholder complaints are common. Under the Affordable Care Act (ACA), consumers have the right to appeal decisions made by their health insurance company.
Denial of a claim
It’s important that you understand your coverages. All plans sold through the health insurance marketplace must cover 10 essential health benefits. Preventive services must be covered with no co-payments, co-insurance or deductibles. However, to be covered, you must receive services from a provider that is in your plan's network. The exception to this is emergency care. If your life or health is in jeopardy, you may go to the closest hospital for urgent care.
Check your insurance company’s provider directory to determine where your insurance will be accepted. You will find this directory at your insurer’s website or in your policy documents.
If you are certain a medical service is covered under your policy, you may ask your insurer to review the claim. The procedure for this will be included in your letter of claim denial. You may need to provide a letter from your doctor to show the service was medically necessary.
If, after a review, the insurance company still won’t pay the bill, you may ask for an external review. This brings in a third party to review your claim. To initiate an external review, contact your state’s Commissioner of Insurance. If you live in a state that does not have an external review procedure, you may file with the U.S. Department of Health and Human Services.
Changes to choice of doctors
While President Obama assured Americans, “If you like the doctor you have, you can keep your doctor,” nothing in the ACA requires your doctor to keep you or your health plan. If your doctor is no longer with your plan, it is an administrative decision made by your doctor’s office. You would need to bring your complaint there. If you cannot convince your doctor to accept your insurance, you will need to find a new doctor. You will have the option of selecting a different health plan during the next open enrollment period.
Problems with referrals and preauthorizations
If your health insurance company refuses to cover specialist services, you may ask the company to review their decision. Follow the same procedure you would when addressing a claim denial. (See above.) If you need urgent care, you may request an expedited review. If, after a review, your insurer still denies coverage, you may appeal to your state Commissioner of Insurance or HHS.
Gillian Burdett is a freelance writer covering all things home and living. Her work can be found on Examiner.com.
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