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Dealing with Health Insurance Claims and Reimbursement Issues

Appendix A: Ten Frequently Asked Questions about Health Insurance Page 2

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Question 3:

My insurance company keeps asking me for more information in regard to many of my claims. Why do they keep asking for all of that information?


In order to make certain that claims are properly reimbursed, insurance companies generally require that specific documentation be included with some claims. For example, if a claim refers to medical equipment, an insurer may ask for a letter from a doctor explaining the medical need for the equipment.

If a claim is for surgery, an insurer may request an operative report -- a detailed description of the surgery -- from a doctor. If a claim is for a hospital stay, an insurer may request an itemized hospital bill, a detailed bill that lists the hospital charges individually. Although those requests may slow down the process, they serve to ensure that the company has made appropriate decisions in regard to claims.

The problem is that insurance companies are not often specific as to what documentation is required to allow for the processing of a particular claim to be completed. At times, that makes it extremely difficult for consumers to be certain how to respond to an insurance company request for additional information or documentation.

Question 4:

My insurer recently denied a large part of a claim because it was above the UCR. That left me with a huge bill that I'm apparently responsible for paying. How does the insurance company decide on the UCR? How can I prevent similar problems in the future?


The UCR (the Usual and Customary Rate) is determined on the basis of a statistical analysis of charges from medical providers in a specific geographic area. Once the UCR has been determined, it generally represents the maximum amount that an insurer will consider for reimbursement, regardless of the actual amount of the provider's bill.

The easiest way to prevent UCR-related problems in the future is to make use of the predetermination of benefits process in all expensive non-emergency situations. The predetermination of benefits process offers the consumer important information, and gives the consumer the opportunity to discuss economic issues with the provider and the insurer in advance of treatment.

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