Health Benefits Appeal Process

759 Words3 Pages
Health Benefits Appeal Process Health Benefits Appeal Process Introduction An estimated 249 million private sector insurance claims will have been filed in 2011 (U.S. Department of Treasury, 2010, p. 43343). If the government sector and the market for individual coverage are included, an additional 70 and 62 million claims, respectively, were expected to be filed. Of these, 48.1 million or 12.6% will be denied. Only a small percentage of denied claims are expected to be appealed, approximately 162,300 or 0.34%, but nearly 40% of these should be successful. This essay describes the appeal process and its benefits. Appeal Process If a health benefits consumer (enrollee) files a claim for medical treatment under their plan rules, the insurer has the right to deny payment after a full and fair review (U.S. Department of Treasury, 2010, p. 43344). The denial of a claim must be accompanied by an explanation for why the claim was denied, any additional documentation generated during review of the claim, diagnosis and treatment codes when requested, detailed instructions for appealing the decision, and linguistic assistance if requested. In addition, the enrollee should incur no cost for the denied claim or for having an appeal considered. There are many reasons a claim may be denied, including obtaining treatment in an inappropriate medical setting (U.S. Department of Treasury, 2011, p. 37216). For example, obtaining medical treatment normally performed in an outpatient
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