Health Insurance Claim Attorneys in Chandler, Arizona 

When the Affordable Care Act (ACA) became law in 2010, the health insurance landscape evolved. For one, it required all Americans to have health insurance and provided options for purchasing subsidized plans depending on one’s income level. It also mandated employers with 50 or more employees (defined as those who work at least 30 hours a week) to provide health insurance coverage. And, it set new standards for insurance providers, such as mandating preventive care and eliminating pre-existing condition clauses in policies. 

Flash forward one decade, and the ACA is still the law of the land. The tax penalty for not having health insurance has been removed, but everything else remains in place. 

But even with the broad protections of the ACA, health insurers still find ways to limit or deny payment for certain procedures and medicines. One problem is that many plans restrict the insured individual or family to using a pre-defined network of health care providers. If you go outside the network to seek a specialist, or because you want a second opinion, your insurer can refuse payment, leaving you stuck with the bill. 

If you have had a claim denied by your health insurer, or you need to file a claim for services that your insurer may be reluctant to cover, contact our insurance attorneys at Arnett & Arnett, PC, in Chandler, Arizona. Proudly serving clients in Phoenix, Tucson, Flagstaff, and throughout the state, we focus our practice on the “bad faith” tactics of insurers and can help you prepare your claim or lodge an appeal to get the treatment or services you need. 

Filing a Claim 

Most times, once you’ve presented your health insurance information to your medical provider, the office staff, in conjunction with the physician or provider, will file the claim for you. If not, filing a claim these days can often be done online. When you sign up and start your insurance policy, you should receive what is called a Summary Plan Description (SPD), which details not only the services covered but also the claims process. 

Generally, there are three types of claims: pre-service claims, post-service claims, and urgent care claims. Another federal law called the Employee Retirement Income Security Act (ERISA) mandates deadlines for insurers to respond to claims, depending on their type. 

A pre-service claim generally involves a request for services from a specialist and generally requires a referral from your primary physician. Under ERISA, these claims must be answered within 15 days. For a post-service claim — e.g., you’ve gone to your primary physician for an illness and received treatment — the insurer must respond within 30 days. For urgent care, the law states they must respond to the claim “as soon as possible” but no more than 72 hours.  

In some occasions, the insurer can request an extension, but that is generally only approved for post-service claims. 

Common Reasons for a Claims Denial 

Insurers have a variety of reasons they can cite for denying a claim. Some are fixable, such as a paperwork mix-up or lack of supporting evidence. Other reasons can be much more challenging to resolve, if at all. 

For instance, when the treatment or service isn’t provided by your plan — this you should anticipate in advance, as your SPD depicts what is covered or what is not. If you do need a service outside of what’s covered, you will need to negotiate with your insurer to prove that it’s medically necessary; and, if it’s offered only by an out-of-network provider, you will need to explain that that is your best and, perhaps, only option. 

Speaking of “medically necessary,” that brings up another common reason insurers can use to deny a claim. For example, you may have sought help from an acupuncturist, but the insurer does not deem this to be medically necessary, even if it is technically covered under the SPD. Other examples could be cosmetic surgery or chiropractic services. 

Filing an Appeal 

If your claim is denied, the insurer must issue you a letter of explanation. Their letter must cite the reason for the denial. You may need to supply additional information for their review, which the letter should also clarify. And, the notice you receive should include information about the company’s review process, that is, how to file an appeal. 

In most cases, you have at least 180 days to file an appeal; but, if you’ve already received the service, your provider may be pestering you for payment, so you should move quickly with your appeal. The insurer is required to have someone other than the person originally denying your claim to review your appeal. The same deadlines for responding to a claim, depending on category of treatment, apply to issuing a decision on your appeal. 

Ready to file a health insurance claim or appeal? When you work with us, your first consultation is free. We will review your situation and advise you of your best options going forward. We are also prepared to help you appeal an adverse decision and will fight for your rights under the law. Reach out now to get started.