Our friends over at ProPublica have posted an important explanation for anyone appealing an insurance claim: How to get your health insurance claim file.
This is very different from posting an appeal: This is the background information the company uses to assess a claim, ProPublica says. “When a health insurance company denies your claim, it creates a file that can include all the notes, phone call audio and other correspondence involved in deciding whether to approve or deny your claim,” they Tweeted.
Anyone appealing an insurance denial is sure to know this: It will take hours on the phone, be unsatisfying and result in many requests for more information — and ultimately, most likely, a denial. This is a different thing.
A simple appeal for a claim denial is pretty cursory, but the background information in the claim history, detailing the information collected in the case, can be very rich. ProPublica has written articles about people with claim files, including one man who got recordings of executives making fun of his claims. Another patient found out how much the insurer thought it would save by denying his claim: “Changing it, a Cigna employee estimated, could save more than $98,000.” Other information that might be included: A nurse’s conversation with a doctor about a patient, a conversation between a doctor and an insurance company representative, and so on.
Who do you ask? How?
Who can ask? ProPublica writes:
“You have the right to request your claim file if you:
- Have insurance through your employer.
- Have a private plan that is not through your employer (known as an individual nongroup plan). Travel insurance plans are not eligible.
- Are under a state or local government plan.
“Similar rights apply to people under Medicaid plans.”
The story says some insurance companies have a way to ask clearly on the site or on their paperwork, but more commonly, facts like the simple possibility of making such a claim and the way to do it are hidden or difficult to find.
So ProPublica offers a template of a request with helpful suggestions. They say the template is one “that you can fill out no matter what health insurance plan you have” and that “it is adapted from one created by Health Law Advocates, a public interest law firm based in Boston that provides free legal services to people struggling to access health care. The template includes:
- “A list of all of the records that should be included in your claim file.
- “Space for you to write in your case details.”
Where do you send it?
Many people feel that communicating with a health insurer is like sending a message in a bottle — whether by fax or by mail, and even by phone (how many hang-ups have you had in insurer calls?).
ProPublica helpfully gives a list of mailing addresses on its “how to file a health insurance claim file” post.
This should be free, ProPublica writes. The results of such a request might be helpful in arguing to overturn a denial, as the patients mentioned above did.
