How Long Are You Able To Dispute Health Insurance Claims?

If you’ve ever had to navigate a health insurance claim, you know they can be complex. Disputes can arise when there are discrepancies between what a policyholder believes should be covered and what their insurance provider has approved.

But how long are you able to dispute health insurance claims?

Let’s take a look at the timelines and processes involved in disputing claims.

About Health Insurance Claims

Before trying to navigate the timelines of a dispute, we need to understand the basics of health insurance claims.

When you receive medical services, healthcare providers submit claims (a bill) to your insurance company for payment. The insurer then processes these claims based on the terms of your policy, including coverage limitations, deductibles, and copayments.

The Initial Claim Review Period

After a provider submits a claim, your insurance company typically reviews it within a specific timeframe, often ranging from 30 to 90 days. During this period, the insurer assesses the claim’s accuracy, determines coverage eligibility, and calculates the amount of reimbursement.

Once the claim is processed, you receive an Explanation of Benefits (EOB) from your insurance company.

This document outlines the details of the claim, including the services provided, the amount billed by the healthcare provider, the portion covered by insurance, and any remaining balance owed by the policyholder.

Reviewing the EOB

It’s crucial to review your EOB carefully to ensure accuracy. Check that the services listed align with those you received, confirm that the billed amounts are correct, and verify that your insurance benefits were applied accurately.

If you notice discrepancies or believe certain services should be covered but were denied, it may be time to dispute the claim.

Disputing Health Insurance Claims

Denial rates for health insurance claims can vary significantly among different insurers.

If you disagree with the outcome of a claim, you have the right to dispute it with your insurance company. Most insurers have specific procedures for filing disputes, which may involve submitting additional documentation, providing explanations, or requesting a review by a claims specialist.

Timelines

While the exact timelines for disputing health insurance claims can vary depending on your insurer and state regulations, it’s essential to act promptly. In many cases, you must file a dispute within a certain timeframe after receiving the EOB, typically as much as 60 to 180 days. Missing this deadline could result in the claim being closed, making it more challenging to challenge.

Nevada Revised Statute (NRS) 683A.0879 states that an administrator must approve or deny a health insurance coverage claim within 30 days of receiving it and make payment within 30 days of approval.

Appealing Denied Claims

If your initial dispute is unsuccessful, you may have the option to appeal the decision through your insurance company’s appeals process.

This process typically involves submitting additional documentation, providing supporting evidence, and possibly participating in a review or hearing. The timeline for appeals can vary but is often within 180 days of the initial denial.

Also, for unexpected treatments received January 1, 2022, or later, you may have protections through the No Surprises Act.

External Review Options

If your appeal is denied, or if your insurer does not have an appeals process, you may have the option to request an external review. External reviews are conducted by independent third-party organizations or regulatory agencies and can provide an impartial assessment of your claim.

The timelines for external reviews vary by state and may depend on the specific circumstances of your case.

Statute of Limitations

It’s important to be aware of any applicable statute of limitations for disputing health insurance claims.

Statutes of limitations set the maximum amount of time you have to dispute a decision, request an appeal, or initiate legal action, and they vary by state and type of claim. Missing the statute of limitations deadline could prevent you from pursuing further action, so it’s crucial to understand and adhere to these timelines.

Seeking Legal Assistance

If you encounter difficulties in disputing insurance claims or navigating the appeals process, consider seeking legal assistance from a qualified bad faith health insurance attorney. An attorney can provide guidance, advocate on your behalf, and help ensure that your rights are protected throughout the dispute resolution process.

A health insurance attorney can provide invaluable assistance in various ways:

• Claims Assistance: Attorneys can help you navigate the complexities of filing health insurance claims, ensuring that all required documentation is submitted correctly and deadlines are met.
• Dispute Resolution: If your health insurance claim is denied or underpaid, an attorney can help you dispute the decision with your insurance company. They can review the denial, gather evidence to support your claim and negotiate with the insurer on your behalf.
• Appeals Process: Insurance lawyers are well-versed in the appeals process and can guide you through each step. They can prepare and submit appeal letters, gather supporting documentation, and represent you during any hearings or reviews.
• Legal Expertise: Health insurance attorneys have a deep understanding of insurance laws and regulations. They can interpret complex policy language, identify violations of your rights, and provide informed legal advice tailored to your situation.
• Litigation: In cases where negotiations and appeals fail to resolve the dispute, attorneys can represent you in court. They can file lawsuits against insurance companies for wrongful denials as well as breach of contract and other bad faith insurance practices.
• Maximizing Coverage: Attorneys can help you understand your insurance policy’s coverage limits and benefits. They can advise you on strategies to maximize your coverage and ensure that you receive the benefits you’re entitled to under your policy.
• Protecting Your Rights: Health insurance attorneys are advocates for your rights as a policyholder. They can protect you from unfair practices by insurance companies, such as wrongful denials, delays in processing claims, or unjustified premium increases.

Overall, a health insurance attorney can be a valuable ally in navigating the complexities of the health insurance system, advocating for your rights, and helping you secure the coverage and benefits you deserve.

Disputing health insurance claims requires attention to detail, understanding of insurance policies, and adherence to specific timelines.

By familiarizing yourself with the dispute process, acting promptly, and seeking assistance when needed, you can effectively advocate for the coverage you deserve and protect your financial interests as a policyholder.

Have questions about a health insurance claim? One of our qualified health insurance lawyers is ready to help you find the answers and make sure that your rights are protected. Contact the Law Office of Matthew L. Sharp for skilled guidance today.