For instance, ask if your employer could send a letter - or place a call - explaining why your claim is valid. Ask your doctor's staff to fix the error and send the paperwork to your insurance again.Ĭall your employer's HR department if you have coverage from your job. Do this for every phone call.Ĭall your doctor's office if your insurance says that your doctor left out information or didn't use the right code. Write the name of the person you talked to, the date, and what was done or decided.
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If you think you may want to appeal the decision, ask the representative to go over the process with you or to send you a description of how to appeal. Be sure to ask if the claim was denied because of a billing error or missing information. It's important to know who to ask for help.Ĭall your insurance company if you don’t know why your claim was denied or if you have other questions about it. Some denials are easier to fix than others. The letter should tell you how to appeal your health plan's decision, and where you can get help starting the process. It should tell you why the claim was denied. Then read over the letter or form your insurance plan sent you when it denied your claim. It also has to list the limitations or exclusions, which are things your insurance won't cover. The paperwork must spell out what's covered. Look over the summary of benefits in your insurance documents. You may be able to get your plan to reverse its decision. If that's what you are facing, you're likely frustrated and upset. ©2022 Texas Health + Aetna Health Plan Inc.You recently had a medical procedure, but now your insurance won't pay for it.
Physicians on the medical staff practice independently and are not agents or employees of the hospital or Texas Health Resources. For a complete list of other participating pharmacies, log in to Information is believed to be accurate as of the production date however, it is subject to change.Īetna, CVS Pharmacy ® and MinuteClinic, LLC (which either oprerates or provides certain management support services to MinuteClinic-branded walk-in clinics) are part of the CVS Health ® family of companies. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are part of the delivery system or physician group. Plan features and availability are subject to change and may vary by location. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. We do not provide care or guarantee access to health services. Provider participation may change without notice. Providers are independent contractors and not our agents. Health benefits and health insurance plans contain exclusions and limitations. An application must be completed to obtain coverage. This material is for information only and is not an offer or invitation to contract. Self-funded plans are administered by Texas Health + Aetna Health Insurance Company. Aetna provides certain management services to Texas Health Aetna. Texas Health Aetna are affiliates of Texas Health Resources and of Aetna Life Insurance Company and its affiliates (Aetna). Each insurer has sole financial responsibility for its own products. and Texas Health + Aetna Health Insurance Company (Texas Health Aetna). Health benefits and health insurance plans are offered and/or underwritten by Texas Health + Aetna Health Plan Inc. Claims issues for reimbursement or coding decisions Our law department makes the final determination if there is any question regarding the applicability of any particular law. If our policy varies from the applicable laws or regulations of an individual state, the requirements of the state regulation supersede our policy when they apply to the member’s plan. The member appeal process applies to appeals related to pre-service or concurrent medical necessity decisions.Īpplication of state laws and regulations For these issues, the practitioner and organizational provider appeal process only applies to appeals received subsequent to the services being rendered. These issues relate to decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. For example, issues related to the provider contract, our claims payment policies, or processing errors. These issues relate to all decisions made during the claims adjudication process.
This quick reference guide shows you when and where to submit disputes Issue types
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