Been denied a health insurance claim? Here’s how to find out what your insurer said to your doctor

An expert has revealed how anybody can access documents explaining why they were denied a health insurance claim – including phone call conversations between your insurer and doctor.

Health lawyer Juliette Forstenzer Espinosa said these files are free to access and can be a ‘treasure trove of information.’

However Espinosa, a senior lecturer of health policy at George Washington University, told ProPublica ‘most people have no idea how to get it.’

This is because insurance companies rarely advertise their services – and details are often hidden in small print.

In some cases, people have been able to uncover errors by accessing audio recordings or documents. Others even claim to have exposed how insurance companies attempt to cut costs at the expense of patient wellbeing.

Health lawyer Juliette Forstenzer Espinosa said the file can be a 'treasure trove' for patients

Health lawyer Juliette Forstenzer Espinosa said the file can be a ‘treasure trove’ for patients

It is possible to access conversations between your doctor and your health insurer for free

It is possible to access conversations between your doctor and your health insurer for free

When an insurance company is deciding whether it will pay for your medical treatment, it will create a claim file.

This includes details about what your insurer is saying about you and your case – including phone calls, emails and notes taken by doctors or nurses.

WHAT YOU NEED TO MAKE A CLAIM FILE REQUEST

1. Your name, address, phone number and the date you sent the request

2. Your plan ID or member ID

3. The unique case number associated with the denied claim

4. The dollar amount of the claim

5. The dates of your appointments, procedures or other services in question

6. The date you received notice the claim had been denied

Little known federal regulation requires most insurance plans to give you the opportunity to review these documents free of charge.

According to ProPublica, you have a right to request your claim file if you have insurance through your employer, have an individual nongroup private plan or if you are covered by a state or local government plan.

People covered under Medicaid plans also have similar rights.

Some companies – such as Cigna and Elevance Health – offer request forms that you can download and fill out, but most companies do not.

This means that it is often up to patients to ensure they include all the necessary information.

You will need to include your name, address and phone number, and the date you are sending the request.

You must also provide your member ID or plan ID, the specific case number associated with the denied claim and the cost of the claim.

The dates of the appointments associated with the claim are also crucial – and the date you were notified that the insurer would not cover it.

If you cannot find any of this information, you can request it from your healthcare provider or from the insurance company directly.

Depending on the nature of your case, you can ask for copies of telephone logs and call summaries, medical records and assessments and even recordings of telephone conversations.

You can request information from your healthcare provider to help with your claim request

You can request information from your healthcare provider to help with your claim request

Make sure you include the dates of the appointments associated with the claim with the request

Make sure you include the dates of the appointments associated with the claim with the request

Be sure to also mention that you are submitting a request for a claim file, rather than an appeal, as insurers can confuse the two.

An appeal is when you ask the company to reconsider its decision if you have been denied a payout – so it is often worth asking for the claim file first so you have all the information you might need if you decide to appeal.

According to ProPublica, when you send out the request it is helpful to include a copy of the denial letter, or the letter the insurance plan sent you explaining how much you owe for the treatment or service.

Most plans will ask you to send the claim to a mail address, and legal experts recommend that you send the request to the appeals department.

Employees there often understand the process best – and don’t forget to send the request through certified mail so you can track it.

According to experts, most people do not know how to access their claimed information files

According to experts, most people do not know how to access their claimed information files

If you have health insurance through your employer you should get a response to your claim file request within 30 days of sending it in.

The results can be revolutionary for patients.

Cigna patient Lee Mazurek told ProPublica how he switched insurers after discovering that a cost-saving program played a part in his denial.

Mazurek had been on a treatment regimen for nearly nine years for his Crohn’s disease, and found out that an employee had estimated changing it would save the insurer more than $98,000.

He was eventually able to continue receiving treatment but was forced to dip into his savings to buy secondary insurance during the process.

A Cigna spokesperson told the outlet that the insurer only suggests changes when clinically appropriate, and that cost is never the sole determining factor and Cigna does not directly benefit from such savings.

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