1. Don't panic.

Health insurance companies are run by humans, and many times it is simply a matter of human error or a lack of knowledge about the situation.

2. Find out why it was denied.

Look over your Explanation of Benefits and determine the actual reason that they denied your claim. Many times it is simply a matter of the health insurance insurance company needing some general additional information from you or from your medical provider. If this is the case, it is often quite easy to have your health insurance claim paid.

3. Get the required information to your health insurance company as soon as possible.

If your insurance company needs information directly from you, give it to them as soon as possible. If it can be done over the phone, do so. If you are sending something by mail that contains sensitive information, you may want to send it by certified mail to verify that they do indeed receive it.

If the health insurance company needs something from one of your medical providers, it will usually take more effort on your part. Sometimes it is simply a matter of calling your doctor and asking them to provide the information. In other cases, you may need to have them complete a specific form. Sometimes medical providers charge you to provide this information to your health insurance company. No matter what type of information you need from them, be sure to do your best to get it to your insurance company as quickly as possible.

4. Follow up with your health insurance company on a regular basis until the claim is paid.

Once you, or the medical provider, have sent the required information to your health insurance company, it is your responsibility to follow up on a regular basis. Many times health insurance companies will receive the information and not immediately connect it with information that they already have on file. Other times, mail just gets sent to the wrong department. They may say they have never received it. You have to be prepared to keep on contacting them until they confirm that they have your information. It's extremely important that you document every contact you have with the insurance company. Have a notebook especially for this purpose. Each time you speak with someone, get their name and position so that you can always reference the person you spoke with the prior time. It lends more credibility to your requests when you call back to follow up.

5. File an appeal with your health insurance company.

If the health insurance company reviews your information and then issues a final denial, you always have the option to appeal their denial. With each denial, you should receive an ERISA document advising the procedure you need to follow if you want to appeal the claim. If you feel that you have a good case for having the claim paid, according to policy guidelines, then follow the steps and take the time to file an appeal. Again, once you file the appeal, keep track of all your contact with the insurance company.

6. If you feel that your claim has been handled incorrectly or unfairly, file a claim with your state insurance commissioner.

Sometimes, no matter how nice and professional you are, your health insurance company does not handle your claim in the correct way. Perhaps they make you wait months on end and do nothing. Or maybe they deny your claim as not medically necessary even though several doctors have documented that they feel that it is. Then it's time to play the ace in your hand.

One term that health insurance companies do not like to hear is, "insurance commissioner." If you threaten to file a complaint with your state insurance commissioner, most insurance companies will realize that they need to take you more seriously. And, if you make this threat, be prepared to follow through. You may not get the final claim resolution that you want, but at least you will have tried. Some health insurance companies get a lot of complaints - others are more responsive.

Generally, you need to call your state insurance commissioner's office and fill out paperwork. This is where it helps to have kept good records in the past when you contacted the insurance company. The more documentation you have the better. The insurance commissioner's office will follow up with the health insurance company and verify that everything was handled in accordance with policy guidelines. If the health insurance company has done something incorrectly, they will usually correct it and you will get your claim paid.

Steven D. Smith is a licensed life and health insurance professional and CEO of SDS Financial, LLC.  He is also the author of the “ 2008 Guide to Choosing and Using Your Health Insurance Plan” and “ Your Guide To Good Health Insurance”.  Other articles and books about Health Insurance written by Steven Smith can be found at his website www.AvoidingBadHealthInsurance.com  

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