If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party. You can ask your insurance company to reconsider its decision. Insurers need to explain to you why they denied your claim or canceled your coverage. Your health insurance company could cancel your coverage if you fall behind on your monthly premiums.
New York consumers are protected from unexpected bills when they are seen by an out-of-network provider at a participating outpatient hospital or surgical facility in their health plan's network. In addition, consumers with health insurance coverage provided by an insurer or an HMO are protected from unexpected bills when a participating physician refers them to a non-participating provider. New York consumers are also protected from bills for emergency services in hospitals, including hospital care after emergency room treatment. Unexpected bills occur when an out-of-network provider treats you at an in-network hospital or outpatient surgical facility, OR when a doctor in the network refers you to an out-of-network provider.
In-network means in your health plan's network. Health insurance claims can be denied for reasons including out-of-network providers or errors in the billing code. When your health insurance doesn't pay a bill, you can appeal the decision and the odds of winning are good. Anyone in the industry can tell you that insurance companies are known for their inconsistent information, and sadly, this essentially applies to every part of the insurance process.
The health care provider or hospital may require you to pay in advance and then request reimbursement from your insurance company; the amount you can expect to receive depends on the type of coverage you have, whether you have already met your out-of-network deductible, and the specific details of your benefits (some plans don't) they cover out-of-network care at all, while others will pay a portion of the charges). If your insurance company decides to deny the claim, it must notify you in writing why your claim is being denied and must do so within certain time frames (this depends on the type of claim). Depending on the situation, they can help you understand the claims and appeals process, understand your explanation of benefits, and contact the insurance company on your behalf. Appealing the denial of a health insurance claim isn't always an uphill battle if the right procedures are followed and valid arguments are presented.
I call my health insurance, they said it didn't cover outside the network, when I buy health insurance no one tells me that the network works. While this may not seem like your fault, it is your responsibility to follow up with your insurance company and health care provider to ensure that all the information necessary to be able to pay your claim is provided and processed. You are only responsible for paying in-network cost-sharing (copay, coinsurance, or deductible) for emergency services. You only have to pay in-network cost-sharing (copay, coinsurance and deductible) for bills for out-of-network emergency services at a hospital.
Make sure you get this confirmation directly from your insurance company, not through your health care provider, as the insurance company has the final word on what it covers. For example, if an incision is required before a certain surgery, your insurance company may “bundle” the two procedures and pay only one claim. Insurers and states have health insurance appeal processes for you to have an opportunity to comment. As long as your health plan is not exempt from rights, the Affordable Care Act (ACA) guarantees your right to appeal claim denials.
At a minimum, if a claim is denied, you should contact the insurance company to request a comprehensive explanation of the denial. .
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