Phone call with your insurer

Have your member number, the claim number and the date of service in front of youThe representative needs these to find the claim, and they are printed on the Explanation of Benefits and the denial letter.Have the denial letter open at the reason and the denial codeYou can then ask about the exact words the plan used instead of describing it from memory.Set up a log with date, time, name, title and what was saidPhone notes with those five details are the record that a later appeal or complaint can rely on.Write down the one thing you want from this callA call about getting a copy of your claim file goes differently from a call about a billing error, so decide first.

What exactly was denied, and what is the denial codeA plan that is not grandfathered must give you the denial code and the diagnosis and treatment codes with their meanings.Is this a denial, a rejected claim or a request for more informationA rejected claim with an error is fixed by correcting and resending it, while a denial is appealed.What clinical criteria or guideline did the plan apply, and can I have a free copyIf the plan relied on an internal rule or a medical judgment, it must explain it or give you a copy free on request.Who reviewed the claim, and was the reviewer a health care professional in the relevant fieldA plan must provide for identifying the medical experts it consulted about the denial.What is the deadline to appeal, and where do I send the appealA group health plan must give you at least 180 days after you receive the denial, and the date on your notice controls.

Ask for any decision or reason to be sent to you in writingA phone answer is hard to use later, and a written reply gives you something to attach.Do not appeal by phone on the first call unless your health is at riskGather your evidence first, because an urgent appeal is the case where the rules allow a request by phone.Put important requests in writing, even if you also say them on the phoneA request for your claim file, your plan document or an appeal needs a dated written record.

Finish your notes within minutes, including anything the plan promised and by whenDetails fade quickly, and a promise with a date is something you can follow up on.Send a short written follow-up confirming what was saidAn email or letter saying who you spoke to, when, and what they agreed turns a conversation into a record.Write the follow-up date on your calendarIf the plan promised a call back or a decision by a date, a note stops the date from passing unnoticed.

Phone call with your insurer

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