How To Question An Explanation of Benefits
If you have questions about your explanation of benefits or think it's incorrect, contacting your insurance company properly and understanding the reason for any denial will increase your chances of getting the claim paid properly.
Before Contacting The Insurance Company
- Review Talking to Your Insurance Company for tips on getting the results you want from the call.
- Determine the cause for the insurance company's refusal to pay.
- If it's a simple coding error, see the next section.
- For other arguments, see: Arguments To Use Against An Insurer's Denial Of A Health Claim.
- Collect information to refute the denial before calling so you have your argument prepared.
- If you can't resolve the issue, and need to appeal it, see: Health Insurance Claims Appeals.
- If you can't determine the reason for the claim's denial, call the claims department of the insurance company to obtain it. If it's a simple error, you can correct it on the phone. If not, ask for time to think about the reason and that you'll call back. This will give you the opportunity to prepare your argument. Saying the wrong thing at this point could hurt your case rather than help it.
Improper Treatment/Diagnostic Code
- Errors in coding are the most frequent reason for incorrect or denied claims. Virtually all billing and claims processing is done with code numbers for both diagnosis and treatment procedures. If one digit is incorrect, it can cause confusion and/or denial of an entire claim.
- Example: Sandra was surprised to see that the insurance company denied a $400 charge on her hospital bill from when she delivered her baby. A coding error had billed her for a craniotomy tray (instruments used to open the skull). The insurance computer threw out the charge as not medically necessary without checking why there was a contradiction.
- What to do: Make sure both your doctor and your insurance company are using the correct, same code(s) for your diagnosis and treatment. A copy of your doctor's bill and the EOB should help you get to the bottom of a "code error" relatively quickly.