How can I effectively appeal a denied health insurance claim?

Question

I have a series of claims ...for chiropractic treatment that has been denied....how can I get these appealed successfully?

Answer 1

It depends on why the claims were denied.

If your chiropractic claims are being denied because you went over your visit limit for the year, then there is nothing you can do about that.  10 visits per calendar year (or whatever a person's benefit limit may be) means exactly that...coverage for no more than 10 visits per calendar year.

If your claims are being denied for lack of medical necessity, then you'll need to have your chiropractor submit documentation for review showing why the visits were necessary.  (Office notes, X-Rays, medical history, etc.)

If your claims are being denied because chiropractic care isn't covered on your policy at all, then there's nothing you can do about that.  (If your policy excludes chiropractic, no appeal in the world is going to change that.)

You should update your question with the reason for the denial, so that we can help you better.  :)

Edit to add:  Did you or your chiropractor call the insurance company before your treatments began to ask if decompression therapy was a covered benefit on your policy?  If you were told prior to the therapy beginning that it was covered, then you need to contact the insurance company with that documentation (date/time of the phone call, who you or your chiropractor's office spoke with, etc.)

If no one called prior to the services beginning and you just assumed they would be covered, then you may not have any grounds for an appeal.  Many (if not most) insurers consider spinal decompression to be experimental/investigational, and and they would have told you that had you called in advance.

Examples:

Aetna's clinical policy bulletin on spinal decompression, stating that they don't pay for it:  http://www.aetna.com/cpb/medical/data/10...

Blue Cross Blue Shield also doesn't cover it.  (Here's the BCBS Tennessee policy, which is similar to BCBS policies in other states:  http://www.bcbst.com/mpmanual/Mechanized... )  Also, several chiropractors in Georgia were sentenced to prison time for fraudulently billing BCBS-Georgia for spinal decompression services!  Case details here:  http://www.casewatch.org/doj/topel/indic...

In other words, I wouldn't hold my breath over your odds of successfully appealing for coverage of these services.  If you want to give it a shot anyhow, you and your chiropractor should send in as much documentation as possible to try to demonstrate that it shouldn't be considered experimental and investigational.  (To be completely honest though, the odds of them changing their minds are slim to none...especially since none of the major insurers are covering it either.  h**l, even the Attorney General of Oregon has prohibited spinal decompression manufacturers from advertising their services in the state:  http://www.devicewatch.org/reg/axiom.sht...  )

As for how you can spare yourself this sort of heartache in the future...call before you have a service like this done!  Either you'll know up front that it isn't going to be covered, or you can submit a request attempting to gain prior approval.

Answer 2

The state where I live mandates that chiropractors are a covered provider. Lot's of states don't have that mandate. Before you go through lots of trouble appealing the denial of claims, make sure that your policy covers such treatment.

The first step is with the insurance company. Step two is with your states insurance commissioners office.

Good luck

Don

http://mtnhealthinsurance.com

Answer 3

That doesn't help.  You need to give us more detail because without detail maybe the denial was justified.

Answer 4

Easy answer question,no.Not solvable question,no.Browse this information,your answer may be here.http://health-insurance.expert-tip.info/...

Answer 5

Refer them to the Insurance Commissioner for your state or better still, the Office of the Attorney General. Show full chapter and verse plus a copy of fhe coverage of the treatment as stated in your health insurance policy. .Make sure that the  chiropractic treatment is covered before you proceed.