"The lack of empathy,
understanding, and support for
parents and families of children with
significant disorders is a national
sin. The issue goes beyond money,
entitlements. It's about the
relationship between people and
their institutions, society's
responsibilities, and ultimately how
people relate and treat each other.
Creative must and will take a lead in
this." - Richard Feingold, co-founder
Creative Health Solutions
|Therapeutic excellence through innovation—integration—collaboration™
3900 Jermantown Road, Suite 250
Fairfax, VA 22030
What you can do when health insurance
claims are denied*
accurately including prompt and accurate filing and reasonable
follow up. Sometimes that is not enough. In that case you need to
- Most health insurance is governed by federal law with
some plans having additional state oversight. Federal and
"self funded" plans are exclusively under federal
jurisdiction. Creative staff will help determine your plan's
- Insurers have 30 days to process a claim--either pay or
provide a valid reason not to. If they deny they must promptly
notify you and provide you a mechanism for appeal.
- The insurance company works for you. Creative works for
you. The insurance company reimburses you the cost of
service based on their fee schedule. For in network claims,
we have agreed to a "contract" fee schedule and typically
wave full payment up front in anticipation of the insurance
- In pursuing fair and equitable treatment, it is important that
Creative and the client continue to work together and
proceed with prudence and caution. Please let us know if
the insurer's reason for denying the claim is a "failure" on
our part--and what the alleged failure is.
Guidlines for calling the insurer
- Take notes. Record names, positions, time and date as
well as time on hold. Use the notes for follow up calls.
- Ask what, why, and who questions. Require specifics. Pin
- When given a reason for denial, ask why it was denied—
medical basis—and what would be approved.
- If they say they need records, find out how and where to
send them. We will provide you electronic copies of the
documentation at no charge. You need to send them and
keep track of when and to whom.
- If they say the treatment code was incorrect, ask them what
the code was and what it should be. Let us know. (Note that
this is strange since OT codes are very limited and the few
we use have worked with all insurers for many years.)
- If you don't get satisfaction ask for a supervisor. If one if “not
available” get a commitment to when they will call you back
and record who and when
- Note that when you are told the claim is “being processed” it
doesn't mean it will be paid. The same holds for when you
are told the claim “should be paid.” Keep a look out for the
EOB (explanation of benefits) and verify.
When all else fails
(Office of Personnel Management). If you are non government,
- If the plan is through an employer, contact your HR
department. Most plans are in fact employee benefits and a
claim denial is tantamount to a reneging on those benefits.
Virginia Insurance Commission has a website with which you can
file a complaint. We will help you.
- If your plan is in network and the claim denial is based on
network criteria (terms like the provider's "credentials" )
consider filing the claim out of network. We will help you.
advice. It is a compendium of the experience of the Creative staff and our
clients. It is intended to help clients obtain the benefits that they are entitled