My health insurance claim was denied. How do I appeal?
You have a right to file a grievance with your insurance company by writing or calling the company. The company will contact you and review your claim internally. During that process you may submit additional information and appear in person.
Ultimately, if your company denies your claim after its internal reviews are finished, you may have the right to an external review. This is a review of your medical records by an independent review organization assigned by the Insurance Department.
For help at any time during this process, contact the Insurance Department consumer advocates at 406-444-2040 or 800-332-6148.
Why is it taking so long for my insurance company to pay the doctor bills?
If the insurance company has all the information it needs, it must pay within 30 days of receiving a claim. However, if more information is needed, the company has up to an additional 30 days.
I received a fax offering insurance for my entire family for less than $400 monthly? Is this legit?
You should be very careful about unsolicited offers for low-cost health care. Many of these offers are scams or don't offer the level of coverage you think you're getting. Can you find the insurer's name on the advertisement? If you can't, it might be a scam because without a name you cannot verify that the company actually exists and its policies are being sold legally in Montana. The Department of Insurance consumer advocates can help you determine whether the company or agents are licensed in Montana, and what the offer is all about.
What happens if I use an out-of-network doctor?
You could pay a lot more money if you don't use a doctor that agrees to accept the amount "allowed" by your insurance company. All insurance companies limit how much they will allow for any covered service. They then pay their share from this amount. In-network doctors, hospitals and other providers agree to accept the amount allowed by the policy as full payment. Out-of-network providers don't. Once your insurance company pays its share, usually an amount less than it pays in-network, you are responsible for the balance.
This balance is in addition to deductibles and coinsurance amounts you pay. Sometimes the insurance company pays the entire claim to you instead of paying the out-of-network provider. In that case, the medical provider can require full payment of all charges from you.
What can I do if my insurance company denies my doctor's recommended treatment as not medically necessary?
Request a copy of any procedures your insurance company uses to determine medical necessity. You can file a grievance and follow review and appeal procedures, including an external review by an independent third party if necessary. Ask your doctor for supporting information to submit with your grievance. Your insurance company must use a medical professional to determine if a treatment is medically necessary.
Someone from my insurance company told me my surgery was covered but, after the operation, the company wouldn't help pay. How can this be?
Often, advance information is incomplete. Final coverage decisions are usually based on details in the medical records. Discussions with an agent or company representative do not change how the policy covers a procedure. The company may, in fact, say that prior authorization isn't needed for a procedure. That doesn't mean it will cover the procedure. The procedure still must meet medical guidelines. Insurance companies have detailed procedure-by-procedure guidelines on when coverage is allowed. You can ask for the guidelines for your particular treatment.
On the other hand, if prior authorization is required and obtained, the company may be required to cover the care you received.
Other reasons for coverage denials include changes in your coverage or enrollment status that you don't know about. For example, your employer may change insurance companies or benefit plans and this happens before you get a new insurance card. Or, perhaps your insurance ended sooner than you expected. Maybe the insurance company made a mistake.
For help getting an answer and information about a possible appeal, contact the Insurance Department consumer advocates at 1- 800-332-6148.
What is a pre-existing condition?
A pre-existing condition is a medical condition for which medical advice, diagnosis, care or treatment was received. For example, perhaps you visited your doctor and discussed your high-blood pressure. Even though you didn't get a prescription for medication, you may have received advice. If you're not sure, ask to see your medical records.
If you are age 19 or older, pre-existing conditions determine whether you can get a commercial health plan in the individual market (for people who don't get employer group insurance). Also, if you are 19 or older, you may have to wait before any pre-existing conditions are covered on an individual or group plan.
How far back in my health history do insurers look? In the individual insurance market, insurers can review your entire health history to determine whether or not to offer you an insurance policy. If you are age 19 or older, insurers look back on your health over a three-year period for individual coverage or 6 months for group coverage to determine if pre-existing conditions can be excluded for up to 12 months (sometimes 18 months in group) during your first year of coverage. What if I am under age 19?
If you are under age 19, recently enacted federal health reform no longer allows insurance companies to deny you coverage because of pre-existing conditions or make you wait before coverage of any such conditions begins.
However, insurers may limit enrollment to certain times of year so that parents do not wait until a child becomes sick to buy coverage.
I lost my job and my insurance, what do I do now?
Public and private insurance programs may help you stay insured if you lose your job and your health insurance. It's important not to delay a decision because some choices have deadlines. Your choices include:
Move yourself and family members to a spouse's coverage.
If your employer stays in business and still offers insurance, you may be able to temporarily continue your same policy under federal (COBRA) or state law. You normally pay the full cost of the insurance policy, and you may be surprised at the amount if your employer has been paying most of the costs.
