Anyone appealed denial by health insurance claim coverage?

[Anonymous]

Carefirst, after giving pre-authorization, is now denying a $1900 treatment. Anyone had luck filing an appeal or bringing a lawsuit against them (or another health insurance provider)?

[Anonymous]

What is the reason for the denial? Did your provider file an appeal? Is your provider actually billing you?

[Anonymous]

OP here--Reason was that it wasn't covered under my plan and "pre-authorization isn't a guarentee of payment". My provider is billing me the whole amount (although had agreed to not "actively seek payment" while the insurance company was processing). I sent an e-mail to my provider this morning to see if he has any suggestions or can do anything to help...

[Anonymous]

In network or out of network? Are they denying the treatment is medically necessary? Saying it's experimental? I work at a doctors office as a patient advocate for out of network claims, but I need more info to be able to help. Is the procedure a therapy that was multiple days, or a procedure on one day? Are they saying it's an exclusion under your plan?

[Anonymous]

Did the doctor code the procedure correctly? What does your plan say?

I actually have appealed and I ultimately ended up winning - but it took a long time of back and forth. Your doctor's billing department should be able to help straighten it out - or if your insurance is through your company, ask your benefits department. I worked somehwere once and the benefits dept rocked. They always helped us with claims, etc.

[Anonymous]

You have to be really careful with your appeal - make sure you meet the timeline, and make sure you provide everything in support of your position. Once you go to sue, you won't be allowed to add anything to the record.