Dealing with health insurance companies: Claims & Appeals

Megan is from the Stride customer support team and is an all around health insurance pro. A licensed agent (maybe the 007 kind? we're not sure yet), Megan can hassle insurance companies like it's nobody's business. Send questions about your plan or application her way.

We know there's nothing you love more than spending hours trying to figure out your health insurance, but we've got a few tips to make the process simpler...just in case.

What’s the difference between an appeal and a claim?

Claim: An itemized statement of services and costs. Whenever you get medical services that you think are covered by insurance - like a doctor’s visit or surgery - the health care provider (your doctor, specialist, etc.) sends a claim to your health insurance company for payment.

In rare cases, the insurance company will deny payment of the claim. If that’s the case, your insurance company must let you know about this denial:

• Within 15 days if you sent in the claim before receiving treatment
• Within 30 days if you already received treatment
• Within 72 hours for “urgent care cases” (situations serious enough that delaying any longer could seriously harm your health)

Appeal: If your claim is denied, meaning the insurance company will not pay and you get stuck with the bill, you have 180 days to send in a request (an appeal) for your insurance company to take another look at your case...or to stick it to ‘em, as we like to say.

How do I file an appeal?

• Find out why your claim was denied. Check for coding errors. Mistakes DO happen! If you believe that the service you’re being charged for is covered, call your doctor’s billing office to go over your bill before filling out any nasty paperwork. They may just need to resubmit the claim with corrected codes. This is called a “Corrected Claim.”
• Fill out some paperwork. To get the process going, you’ll need to file an appeal with your insurance company by mailing in all this information (such fun):
  • Your insurance company’s specific appeal form (you can find this online).
  • A letter explaining why you’re appealing - as much detail as possible!
  • A copy of the denial letter and an Explanation of Benefits form that show which services were denied
  • The original claim
  • Any extra documents that support your argument (eg. office notes or medical records)
  • Notes and dates from any conversations you may have had with your insurance company or doctor about the appeal, including the name and title of the person you spoke to. Pro tip: At the end of each call, always ask for a Call Reference Number. This number will help the insurance company pull up a record of your call.
• Respond accordingly. If your appeal is accepted, celebrate! If it’s denied again, you can appeal once more. Another option is to use medical bill advocates like CoPatient; they negotiate bills, find mistakes like duplicate charges or billing errors, and more (note: they do charge a 35% fee on however much you save).

For even more information, check out the government's explanation of how things work. Surprisingly, it's pretty straightforward!

Extra Tips to Keep in Mind

At Stride, we try to brave the hold music as much as we can so you don’t have to. Our team has spent countless hours on the phone with insurance companies, and this is their expert advice:

If you’re appealing:

• Request an Explanation of Benefits (EOB). This is a form sent by your insurance company that has details about a covered health service. It will show exactly what has been paid and what has been denied.
• Always keep copies. Things like claims, EOB’s, even notes from a conversation with your doctor are all your secret weapons!
• Write a detailed letter. When you’re sending in your appeal letter, include useful information to make the process smoother. The top of your letter should look something like this:

If you end up calling the insurance company:

• Have all your information ready. Be prepared with the date of your claim, your Social Security number, and your ID number.
• Ask for an on-shore rep. If you’re speaking with an off-shore rep and it’s not working out, don’t be afraid to ask for on-shore rep. They’ll most likely transfer you to someone else who can help accordingly.
• Get a reference number. At the end of each call, always ask for a Call Reference Number. This number will help the insurance company pull up a record of your call.