Anyone who has filed a medical insurance claim and had it rejected because it was “not necessary, is experimental or is part of a ‘medical investigation,'” will be glad to know that the state of Oregon is offering help to take your appeal a step further. Keep reading:
The Oregon Department of Consumer and Business Services (DCBS) now has an online guide explaining how to appeal a health insurance claim that is denied by your insurance company. The guide can be viewed by clicking here.
A relatively small number of Oregonians with health insurance – roughly five in 1,000 – file appeals, according to 2009 data from Oregon’s largest health insurers. However, more than 44 percent of those who appeal succeed in getting the denial overturned, generally by the company through an internal appeal.
“Consumers should know that they often benefit by asking their company to take another look at their claim,” Insurance Division Administrator Teresa Miller said. “Often, additional information is needed to clarify whether something is covered under an insurance policy or is medically necessary or to correct an error in paperwork.”
If consumers exhaust appeals to the company, denials involving such issues as whether a procedure is medically necessary or whether it is experimental or investigational may be appealed to an Independent Review Organization. In these cases, the Oregon Insurance Division assigns the case to a third-party expert who is not affiliated with your insurance company.
The division’s consumer advocates are available to answer questions about appeals and to help guide consumers through the process. They can be reached at 888-877-4894 or 503-947-7984 in the Salem area.