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Making Claims and Appeals with Kentucky Health Insurance Companies

How to make claims and appeal denials

Before you file a claim:

• Review your policy or employee booklet carefully to be sure the service in question is covered.
• Follow any managed care rules, including precertification requirements and the use of network providers.

Submitting a claim:

• Find out if your provider submits the claim for you or if you need to do it. If you need to file the claim, review the information to be sure it is complete and correct.
• File the claim as soon as you get the bill from the provider and be sure to send it to the right address.
• Keep a copy for your files.
• Allow reasonable time for the company to process your claim. The company will inform you if it needs additional information to complete the claim. Often, it will request the information directly from the provider. After the company has all the information it needs, it has a certain number of working days to process your claim. The company must send you an explanation of benefits to explain its decision.

If your claim is denied:

• The reason for the denial should be stated on your explanation of benefits.
• If you disagree with the reason stated for denial, check your policy or employee booklet for the company's appeal procedure. The company should be able to answer procedural questions about appeals over the phone.
• Your appeal should be in writing and may require information from your doctor.

For more information about appeals, read What You Should Know About Health Insurance Appeals, a free publication available online or by calling the Department of Insurance.

To file a complaint

If you've tried unsuccessfully to resolve the claim problem with your company or agent, you can contact the Consumer Protection and Education Division of the Kentucky Department of Insurance. You will be asked to file a written complaint. Please include the following:

• Your name, address and daytime telephone number.
• A description of the problem from your point of view. Include the name of any insurance companies involved, policy numbers, what type of insurance, etc. Be as detailed as possible.
• Supply any documentation you have to support your case. This includes any correspondence from the insurance company and copies of your explanation of benefits.
• What you have done to resolve the problem.
• A copy of both sides of your insurance card.
• Mail complaints to Kentucky Department of Insurance, PO Box 517, Frankfort KY 40602-0517. You can e-mail complaints or use the online complaint form on the agency Web site.
• Do not send originals.