My insurance isn’t paying my claim because they say it’s not a covered benefit. But my doctor says it’s medically necessary. How can I force them to?

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Aug 13, 2020

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You may not be able to. It depends on the exact wording of the policy. In general there are three possibilities: 1) the procedure in question is covered, 2) it is covered only if medically necessary, or 3) it is not covered. What options you have depend on which of the three it is.

If the medical procedure in question is listed as a covered benefit in the policy, then you’ll first want to talk to the claims department and find out if there has been some sort of mistake. Was the claim submitted too late? Was it submitted incorrectly, with an incorrect diagnostic or treatment code? Were all the needed authorizations included with the claim? If any of these are wrong, you’ll need to have your doctor resubmit the claim with the correct coding.

If the procedure is typically not covered, but you have an unusual or exceptional policy with your insurance carrier, then bringing the terms of the policy to the attention of the claims adjuster is usually enough. Similarly, if you have had more than one type of policy with the same carrier, sometimes the adjuster may only see one of them – the wrong one – and apply your claim to it. If you suspect this, then raise the issue with the claims adjuster or a superior if necessary.

If the policy allows for this particular procedure only in exceptional cases, and where state laws and the policy itself provide no sure guidance on “medical necessity,” you’ll need to ask your doctor to talk to the carrier’s utilization review department. This is not something you can do yourself; the doctor is the one who has to convince them of the medical necessity. You’ll probably have to go through the policy’s appeals and review process, where your claim will be considered and reviewed. You can find more information about the review process in your policy, or your customer care representative can help as well.

If the procedure or treatment you received is simply not covered under the plan, they are not obligated to pay for it. Medical necessity applies to medical services and you — not to who pays for those services. It tends to be defined in insurance contracts because, much to our dismay as consumers, it usually serves to limit their liability – not extend it. Check with your state insurance commission for more details on your carrier’s requirements to pay in your state.

If your policy is self-insured (your human resources department will be able to tell you if this is the case), then your policy manager in HR may be able to authorize an exception for you. Be prepared to sign a HIPAA release (regarding health care privacy and information) if you go this route. If the plan is fully insured (again, your HR can tell you which it is), then they can still request the exception; they just can’t guarantee it. Still it can’t hurt to get them involved. Be patient with these processes, and know if and when it’s not worth it to you personally to pursue the claim.

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