Summary of Traditional Individual and Group Plans, Doctors' Bills

Part 2, Chapter 4: Traditional Individual and Group Plans, Doctors' Bills Page 21

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An insurance policy represents an agreement. In an individual policy, the agreement is between the consumer and the insurance company; in an employer-sponsored group policy, the agreement is between the employer and the insurance company. In either case, the treatments, tests, and services covered by a health insurance policy are always limited and are always subject to detailed policy rules. In order to obtain the health insurance benefits to which you are entitled, you need to understand those policy rules and you need to become familiar with some of the more common claim problems and their possible solutions.

Those problems may include difficulties related to

• yearly deductibles;
• procedure codes;
• the UCR and percentiles;
• secondary insurance benefits;
• claim denials on the grounds that the treatment or service does not represent a covered expense, is not medically necessary, or is experimental.

Fortunately, there are a number of responses that may be effective in such situations. Those responses include the possibility of filing a claim appeal with your insurer, or seeking help from

• your county or state medical society;
• your state Department of Insurance;
• your state Department of Health;
• appropriate federal agencies;
• self-help or advocacy groups;
• a private medical claim-processing company;
• an attorney;
• state or federal legislative representatives.

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