Posted on 11/23/2023 12:48:22 AM PST by texas booster
What’s a Claim File? Why Should I Request One?
A claim file is a collection of the information your insurer used to decide whether it would pay for your medical treatment or services. Most people in the U.S. facing a denial have the right to request their claim file from their insurer. It can include internal correspondence, recordings of phone calls, case notes, medical records and other relevant information.
Information in your claim file can be critical when appealing denials. Some patients told us they received case notes showing that their insurer’s decision was the outcome of cost-cutting programs. Others have gotten denials overturned by obtaining recordings of phone calls where company staff introduced errors into their cases.
By law, health insurers’ responses should be timely and the records provided by the company should explain why they denied your claim or prior authorization request. However, ProPublica has found that some insurers don’t respond to claim file requests, or they do respond but send inaccurate or incomplete information. If this happens to you, see “I submitted my request but am having trouble getting my claim file. What can I do now?” under “Other Questions” below.
Answer a few questions to generate a PDF of your claim file request letter.
Mail, fax or upload the completed letter to your health insurer.
Your claim file request should be fulfilled within 30 days.
If you agree to be contacted, we’ll email you later to see if you’ve received your file.
Because that’s their job. They make the process so burdensome for providers. The US insurers appear to take turns administering Medicare. So they are morally corrupt. Find a real doctor, pay cash and be well.
Ask the folks in the three branches of government about their rates of denials, their benefits and such.
They take your premium and deny your claim. That’s how they make more money.
Most of the denied things I get from my supplemental insurance are because Medicare denied something. They deny anything Medicare does so the fight to get it paid starts with CMMS.
It was hard learning but I always ASK now BEFORE any procedure, test, whatever if it’s medicare covered and covered by my secondary insurer. If the doctor/facility isn’t sure I make THEM get a pre approval before anything happens. That way I’m not gonna get burned on tests like Hep A,B, and C I didn’t need and my doctor didn’t realize how much they cost.
Even if they get a 5 percent denial.
That is a huge amount of extra money they get to keep and not pay out.
I went trough the process a couple of times.
It sure seemed like they were just trying to wear me down so I would pay. Saying it wasn’t worth the time to fight it.
The whole medical claim process is contractual. The insurance people that determine what they will provide put it into a contract that the insured determines to be adequate for them and they sign. It’s as simple as that.
If you go into a medical emergency for a heart attack and decide while you’re in you are going to get your nose fixed, that isn’t part of the deal. You pay for that or you find an insurance comapny that will cover cosmetic surgery. And everythng is to support the business. If the insurance company doesn’t exist, there is no coverage of anything.
This crying over the limitation of a doctor to do work and trying to blame the HMO so they can cop out of possibly being cheated out of their pay by the public is nothing more than finger pointing. The HMO’s are up front with what they will and will not cover. And they do not cover everything all the time. Some cover more than others but you pay for that. Medicine like building a house is business. And the amount of money you are willing to spend will destine the size of the house. But that decision is yours and not the doctor’s. He is only concerned with getting paid to do services. Ask him/her if he/she would do it for half off? You’ll get your answer. And trying to mix emotion with business doesn’t always end happily. But conractual committment is solid or can be made that way.
wy69
What you said, if it isn’t covered in the policy, it’s on you. READ your policy coverage and always, always demand the provider get a preauthorization.
I get a statement of services every month. Included in the package is a claim file.......... every month
And understand the purpose of insurance.
Insurance exists for a reason.
A very good reason.
My beef isn’t with insurance.
It’s with Deep State.
Most denials are due to no preauthorization...
Wow, what trite comics. Is the article aimed at the comic book generation?
You are wise. The people who define healthcare, the UN, the WHO, and apparently the news sources who place blame on the insurance companies are not doing medicine, they are doing politics. A doctor, for instance, is not regulated to carry out cure, they can do that anytime. What they are not doing is getting paid to do it if the insurance policy says they won’t. So what stops them? The good old dollar not the standard of care.
wy69
I had 40 years as a provider and therapist. Retired now and loving it!
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