Why Aren’t These Claims Being Paid?

“Why aren’t these claims being paid?” is a question we often hear in our office. Here are some of the reasons why they aren’t being paid:

1. Once a year the insurance carrier will send you a “coordination of benefits” letter that you MUST answer. They want to determine if they are the primary insurers for you. Perhaps you have a spouse and have coverage under his/her plan too. If you don’t reply to this letter, the claims will not be paid and every time you go to the doctor, you will get another letter. If you are currently dealing with such a scenario, call them up and explain the correct answer to them.

2. Perhaps you have seen a provider (physician, etc.) who is not in the network. Have you submitted the claim? If YOU don’t submit the claim for an out-of-network service, it can’t get paid. Physicians’ offices usually do not submit out-of-network claims. It is your responsibility.

3. Is the service rendered eligible under your plan? This past week I had a person come to see me because she was really very upset with her insurance carrier – “they aren’t paying anything”! Well it turns out that she is getting alternative medical treatments by a homeopathic physician (not covered) and prescriptions are being filled in Great Britain. Her plan does not cover alternative treatment nor does it pay for drugs purchased outside of the country. Be sure to check your benefits booklet by looking for the “Exclusions” page. This lists the items that are NOT covered under your insurance.

4. The most common reason the claim isn’t paid is because it went toward the deductible! Read your explanation of benefits. It contains a wealth of information.

5. Frequently, the insurance company needs additional information. This will be stated on the explanation of benefits. Read it and give them the missing information they need.

6. Perhaps you need a letter of medical necessity for the service rendered or the durable medical equipment (wheel chairs, hospital beds, commodes, etc.) Get the letter from your physician. Often he/she will write in on a prescription pad and that will be just fine. Make a copy for your records.

7. Is the identification number correct? So simple but often it is so wrong and then your claim cannot be paid. Is the date of service correct and complete? It is not July 18^th; it is July 18, 2004.

Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance Claims, Inc. a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, browse our past columns on our web site at www.micinsurance.com.

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