Health Symphony Message Board of Submitted Health Insurance Questions

Question

Response

Appeal Letter to Use

"My claim was denied because I did not obtain an authorization to see a specialist.  Shouldn't my PCP taken care of this?" "If you were referred by an in-network physician, the authorization should have been obtained by the PCP."

Lack of Authorization Appeal Letter

"We did not authorize the emergency room stay, but did we need to if it was an emergency?" "Explaining the emergency situation and the justification that the medical services provided were necessary are needed to appeal."

Emergency Room Appeal Letter

"I took my kids to the pediatrician where he prescribed a medication that I thought was covered by our health plan.  It wasn't" "The prescription drug must be checked against the plan's drug formulary and appealed for medical necessity."

Prescription Drug Appeal Letter

"My physician submitted a bill for my routine annual exam, which is a covered benefit, but my health plan incorrectly denied it.""  "Health plans can make upwards of 10 to 15% errors on claim considerations.  This should always be appealed to have the health plan reconsider the claim submission."

Health Plan Incorrectly Processed Claim Appeal Letter

"My physician treated me for a headache, but he placed as a diagnosis some other type of mental nervous disorder, which my health plan denied my claim?"  "An appeal explaining the error on the claim initially along with a submission of a correct claim is required."

Physician Billed an Incorrect Diagnosis Appeal Letter

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