How to File a Managed Care Claim Appeal

Managed care is a broad term used to describe the vast majority of health insurance companies in the United States today. All of these companies arose from the same need: to reduce the risk of health care by setting up networks of doctors and specialists who would agree to better treatment at lower costs through smart decision making. Unfortunately, the goal of managed care organizations was not met. Today, managed care claims are rejected by insurers, leaving policy holders to pick up the bill. When you have been denied coverage, file a managed care claim appeal to resolve the issue.

Discover Why Claim Was Denied

Your managed care organization has a legal obligation to provide you with an explanation of why your claim was denied. You can often find this information through your provider's website to save you time. Many policy holders will be surprised to find out a claim was denied simply because it was not filed correctly or was coded improperly. If this is the case, then resubmitting the claim the right way is all you will have to do. If you find out your claim was denied for another reason, you should ask why and under what circumstances it would be covered.

Fix the Problem

This sounds simple, but this is the hardest step in the process. When your insurer tells you the circumstances that would have to be present in order to approve your claim, you will have to go about assuring these are actually present. For example, your insurer may insist that your primary care physician provide a more extensive evaluation before referring you to a specialist. As such, your claim at a specialist would have been denied. You should return to your primary care physician with this explanation. The physician may know he or she completed the examination according to policy, and the physician may simply provide more detailed notes for the insurance company to show this. If an incomplete examination was given, then you should question your physician about how to resolve the problem. You may be able to get a retroactive referral. No matter the reason for your denial, the key will be to take documented information to each of your doctors and work with them to have the claim covered.

Resubmit the Claim

You should document each step you take to resolve the problem in writing. Then, submit a new claim to your managed care provider. In this claim, include a letter stating: one, the reason they gave you for a claim denial; two, the steps you took to repair this problem; three, proof the problem has been repaired. If this becomes complicated, you may seek a managed care claims appeal specialist. This person is typically employed by a benefits broker or insurance broker, not by the insurance company itself. An appeal specialist will charge you for the service. It only makes sense to go through a specialist if you are facing a bill significant enough to justify the added expense of hiring an outside source to appeal it.


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