Healthcare Insurance Support Services

Indeed, here’s a brief explanation of each healthcare insurance type that our services cater to:

• Medical insurance: This type of insurance covers medical expenses, such as doctor’s visits, hospitalization, and prescription drugs. Medical insurance may also cover preventive care services, such as annual check-ups and vaccinations.
• Dental insurance: Dental insurance covers dental care expenses, such as routine check-ups, cleanings, fillings, and other dental procedures.
• Pharmacy insurance: This type covers prescription drugs and, depending on the policy, may also cover over-the-counter medications.
• Supplemental insurance: Supplemental insurance is designed to provide additional coverage for expenses not covered by other insurance policies. Examples of supplemental insurance include cancer, critical illness, and accident insurance.

Our team of experienced professionals can also assist with appeals related to mental health and substance abuse coverage, an essential aspect of healthcare insurance. Additionally, we provide guidance and support for appeals about life insurance, which can help you secure the coverage you need to manage your medical expenses. By working with us, you can easily navigate the appeals process and increase your chances of obtaining the coverage you require.

Medical bill claims can be denied for a variety of reasons, including:

• Medical Necessity: The insurance company did not deem the Service or treatment provided medically necessary.
• Excluded Service (s): The insurance policy does not cover the specific Service or treatment received.
• Experimental/ Unproven Procedures: The Service or treatment received is considered experimental or unproven and not covered by the insurance policy.
• Mental Health Parity: The insurance policy does not provide the same level of coverage for mental health and substance abuse treatment as it does for physical health treatment.
• No Pre-Authorization: The insurance policy requires pre-authorization for particular services or treatments not obtained before receiving the Service or therapy.
• Out-of-Area: The Service or treatment received was outside the insurance policy’s approved coverage area.
• Reasonable & Customary: The insurance company deems the amount charged for the Service or treatment as unreasonable or not customary for the area.
• Processing Errors: The claim was denied due to errors in processing or submitting the claim.
• Custodial Care: The insurance policy does not cover custodial care, which is care that helps with daily living activities but does not require medical training.
• Timely Filing: The claim was not submitted within the insurance company’s required timeframe.
• Coordination of Benefits: The claim was denied due to another insurance policy being primary for coverage.
• Provider Definition: The provider who performed the Service or treatment is not recognized by the insurance company.
• Urgent & Emergent Care: The Service or treatment received was not deemed urgent or emergent by the insurance company and, therefore, was not covered.
• COBRA: The insurance policy was obtained through COBRA, but the policyholder failed to pay their premiums on time, resulting in the policy being terminated.

It’s crucial to understand your rights when it comes to healthcare insurance coverage. Unfortunately, many people are unaware of their rights, and the information may not be readily available. Large insurance corporations can be intimidating to question, which may discourage people from researching their rights further or challenging a claim decision they feel is unjust. However, it’s essential to remember that you have several rights if your medical insurance denies a claim. These include:

• Obtaining a full, fair, and thorough review of your appeal.
• Collecting copies of all documentation related to the denial of your claims.
• Receiving copies of your insurance plan documents.
• Obtaining expert claim representation and assistance throughout all levels of the administrative appeal process
• Filing insurance department and employer complaints on claims and appeals that are stalled.
• Requesting independent medical reviews for several denial reasons after internal appeals are exhausted.

FixMyClaim helps families with medical insurance claims by ensuring they are submitted correctly and responded to fairly. One common reason for denial is a medical necessity when the insurance company does not believe the treatment received is necessary. However, denials of medical necessity can be appealed. A detailed timeline of events that led to the treatment must be provided to appeal. Different insurance providers have differing medical necessity criteria, but we are experienced in building strong arguments against this denial. There are two internal levels of appeal before an independent review board (IRO) can be requested. The IRO comprises medical professionals not affiliated with the insurance company, but litigation may be difficult if the IRO upholds the denial. FixMyClaim works with families to determine the best path for their situation.

If you believe that an insurance company has acted unfairly or improperly and are not satisfied with the response from the insurer’s customer service department, file a complaint with your state insurance commission. Some common reasons for filing a complaint include:

• Timely filing: The insurance company did not process your claim within the required timeframe.
• Coding problems: The insurance company incorrectly coded your claim, resulting in a denial or incorrect payment.
• Additional information needed: The insurance company requested additional information to process your claim but did not provide clear instructions or adequate time to submit it.
• Unprocessed claims: The insurance company did not process your claim, resulting in a denial or no payment.
• Processing error: The insurance company made an error in processing your claim, resulting in a denial or incorrect payment.
• Prompt payment error: The insurance company did not pay the claim or pay it promptly as required by law.
• Refund request: You overpaid your premium or were incorrectly charged and need a refund from the insurance company.

When your insurance claim is denied, one of the first steps you should take is to review your insurance policy. Many individuals are unaware of their right to receive copies of their insurance plan documents and documentation related to their claim denial. You can obtain this information by contacting the individual or organization that issued your insurance. If your insurance was issued through an employer, contact your employer, and if it was issued through the healthcare marketplace, contact the marketplace. Even if they cannot provide you with a copy of your plan booklet, they can direct you to where you can obtain your insurance policy.

An insurance policy review is critical in determining whether your health insurance denial was issued in error. Health insurance carriers insure millions of Americans under thousands of plans, so claims processing centers often default to the most common plan language and terms when deciding to approve or deny claims, resulting in errors. We have discovered several common health insurance denial errors during policy reviews, including incorrect payment amounts, misapplication of preauthorization penalties, and incorrect applications of plan terms and definitions like the definition of medically necessary services.

While this list is not exhaustive, these are some of the most common reasons for incorrect claim denials.

As a patient, it’s important to know that the No Surprises Act protects you from unexpected medical bills and ensures that you only pay in-network costs for certain out-of-network services. If you feel that your insurance company has not provided you with fair compensation or violated the No Surprises Act, FixMyClaim can help you navigate the claims process and advocate for your rights with expert guidance and support.