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It is not that unusual to have a dispute with your health insurance provider about what they will cover and what they will not. To work through these situations we have provided the following steps for consideration when resolving these types of issues. What ever tactic you opt to take, it always pays to speak with the insurance company before you incur any costs and get the potential expenses pre-approved. In addition, if you do have a dispute, be prepared to be persistent and do not be easily dissuaded while maneuvering through the bureaucracy you are sure to find.

  1. Know your rights: The plan document or your healthcare insurance plan will tell you what is covered and what is not. Speak with the HR manager at your company and explain what is happening and if they agree with the way your particular situation is being handled.

  2. Speak to the insurance company: Call your representative at the insurance company and discuss with them why your claim, our request for payment pre-approval, was denied. Do not hesitate to ask to speak with that person's boss if unable to come to an agreement.

Still no luck? Write your insurance company a letter that includes:

  • Your name, your group number/ social security number and the name of the insured person.

  • The procedure that was recommended and why it is necessary.

  • The reasons your insurance company gave for denying the claim and the date of the letter or phone call in which your claim was denied.

  • The reasons you believe the procedure should be covered. Include any information or helpful language that you found in your policy.

  1. Get it in writing: Ask for a letter detailing the clinical reasons your claim was denied and the name and medical expertise of the responsible, to better defend your case.

  2. Keep records: Make copies of all correspondence, including payments and any reimbursements. Also, keep a written log of all conversations relevant to your claim.

  3. Find advocates: If you come to an impass with the insurance provide, enlist the help of your doctor, employer, and State Insurance Department to lobby your case. For a list of your state insurance regulators, click here.