Insurance Guidelines

Insurance Guidelines 2017-12-04T13:03:16+00:00

What you can do when your health insurance claims are denied.

Basics

  • 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 category.
  • 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 reimbursement.
  • In pursuing fair and equitable treatment, it is important that Creative and the client continue to work together. 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.

Guidelines 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 them down.
  • 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 and/or send them for you.
  • If they say the treatment code or diagnosis was incorrect, ask them what the code was and what it should be. Let us know.
  • 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

  • If the plan is through an employer, contact your HR department. Most plans are in fact employee benefits and a claim denial may be a failure to meet a contractual or legal obligation.
  • Virginia Insurance Commission has a website with which you can file a complaint. We will help you.