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Appeal Timely Filing Denials

Health Plans are always finding ways to invent not paying a claim.  One of the most popular types of claims denials came as a result, and that is denying a claim that is untimely.  Most health plans have a defined time period on which to submit a health insurance claim and if the claim arrives beyond this date, the claim is denied.  A claim appeal is used to override this very common denial.   Some important things to know about Timely Filing Denials, include:  

1. For most health plans, you must obtain a referral from your primary care physician.  If one is not obtained, it would be very difficult to overturn this denial. 

2. You must also obtain an authorization where required by your health plan.

3. Your symptoms/diagnosis required for Specialists care must be specific and detailed by your physician in your medical chart.

4. Denials could be properly appealed depending upon the support by your physician proving medical necessity and the focus of your argument within the appeal letter.

How do you combat a denial to a specialist? The following steps may help.

1. Review the denial with your policy booklet and verify that their denial is justified. If their reason for denial is unclear, call the customer service unit at the health plan for a more descriptive explanation. Record your conversation and document the name of the individual you spoke with for future reference.

2. Does your health plan cover Specialist care and did you abide by the policy and limitations by the plan?

3. Verify that the Specialist Care you sought is a covered benefit under your health plan.  If not, then you will need your physician's assistance to appeal to the health plan with a letter of medical necessity and all accompanying medical records (pathology reports, operative reports) required by the health plan to justify the medical treatment by the Specialist.

• Appeal the denial yourself by using one of our Appeal Letters.  Our Appeal Letters have been used by actual medical providers and provide arguments embedded within the Appeal Letter to make your case to the health plan to overturn your denial.  To review available appeal letters, click here and review the List of Available Appeal Letters related to Non Participating Providers.