Health Care: Resolving Billing Problems and Claim Denials


There are 5 sections to this tip sheet:

  • Billing disputes
  • Denied claims
  • Formal review – internal review/appeal
  • Formal review – external/independent review
  • Chart: state agencies that regulate HMOs and PPOs

Billing Disputes

Health insurance can be a confusing system, with some people never understanding their policies. Medical billing services that should have been covered by your plan or thought to already be paid may show up in the mail after an accident has occurred!

Resolving Billing Problems and Claim Denials

Health insurance can be confusing, but it’s important to know the difference between co-pays and deductibles. Co-pay is what you pay out of pocket for services like doctor visits or prescription drugs while Deductible refers to your total costs before coverage kicks in which could include anything from doctors’ appointments all the way up through major surgery – if needed!

You can find out more about how billing works by taking a look at

and clicking on Billing Examples in the left menu column – there are different options for your plan, but this should give you an idea of what they’re all about!

Documenting your phone calls is an important way to strengthen any case. Make sure you write down the date and time of each call, who was called or contacted by this document LA Times article, and what discussions took place during those conversations (i.e., did they resolve anything?). If there are going to be future follow-ups needed, then having records like these will give us greater insight into exactly how much progress has been made so far!

You Received Bills for administrations That Should Have Been Billed to your Health Plan

1. Does Your Insurance Cover the Billed Services?

It is important to understand the exclusions in your particular policy so you are not unexpectedly exposed. The Summary Plan Description or Evidence of Coverage should be checked for any overlooked services that may become an issue later on down the road, like maternity care and job-related physicals which often aren’t covered by many health insurance plans even though they’re listed as exclusion items.”

Make sure that you verify the correct billing code was used. It may be a simple typo, which will result in incorrectly charging your account and wasting money!

2. Do You Have an Annual Deductible And/or Out-of-pocket Maximum? If So, Did You Satisfy the Amounts?

What are my options for paying medical bills this year, and what does each option mean in terms of insured vs. uncovered expenses? For example, an individual who has met their deductible for the current year may still have some out-of-pocket costs before the insurance covers everything; but if they reach up until reaching protections offered by employer-sponsored plans or other types such as Medicare supplement policies which can provide additional protection against high fee specialists visits.

You can also ask questions about your coverage by checking the summary plan description or explanation of coverage that was sent to you when enrollment happened. If there are still doubts, call their customer service department for assistance!

3. Did the Health Care Provider Bill Your Insurance?

Insurance companies are notorious for denying claims and forgetting to bill patients. Make sure that they indeed billed your health plan before assuming anything!

It can take up to 30 or 45 days after a medical emergency for an insurance company’s claim approval and processing, but if it has been less than two weeks since you needed care then there is probably no reason why paid denial.

4. Check Your Bills Regularly to Manage Claim Denials with Your Insurance

You may have a right to be reimbursed by your plan for some of the cost if it is paid, but before receiving payment or applying funds against an account there should first be validation. If you disagree with any decision made about your claim, then consult either through internal reviews as mentioned above in the Formal Review sections below – they might provide more information on what steps can take next!

5. If Your Insurer sponsors the Bill, Check the Office that Sent You the Bill.

Your payment could take some time to process because it went through an outside source like a third-party biller or provider. If you have not heard back from us after thoroughly checking on the matter, please reach out again!

You Continue to Receive Bills for Services That Were Already Paid for by You And/or Your Insurance:

1. Keep in Touch with The Billing Department That Is Sending You the Bills

To find out about your current balance, contact the billing office. They may have sent in payment before any payments were applied to it and if that is true then you should be able to get back to them easily enough by emailing or calling their customer service department with questions regarding this issue!

You have a few different options for resolving the billing issue. Be our guest if you want to talk about it over the phone! You can also fix this on your own by finding out where things went wrong with their system and how that led them into confusion.

2. Compare All Relevant Receipts, Bills, And Statements on Your Own

You must gather all of your receipts, credit card statements and cancelled checks from the past year in order to ensure that there are no mistakes on any accounts. You should also review bills sent by providers as well as EOBs given out by insurers because an unnoticed mistake can lead you into big trouble with debt collectors or worse!

Now that you know how to find out if your doctor has been billing for the wrong services, here are some tips on what else might be happening. Your health care provider may have given different prescriptions at one appointment but charged them separately on separate statements- in which case they should be looked into immediately! You also want paper trails when contacting them so no time goes by without being heard because oftentimes these situations don’t get resolved quickly or ever at all.

There are many situations where it is best to get legal help. One of those times, if you have tried unsuccessfully and your insurance isn’t involved in the billing dispute with a healthcare provider you may want to contact an attorney specializing specifically in health law issues so they can provide more information about what options exist for solving this problem.

Denied Claims

There is usually a time limit for filing an internal review or appeal, so don’t lose the possibility of formal action because you didn’t act fast enough. Always keep records of all phone calls and documents in case something goes wrong later on; if someone else handles your looked-into matter make sure they follow up within specific deadlines too!
If you’re not sure whether your claim was covered by insurance, contact the company that provided it. You can find this information in detail on their Summary Plan Description or explanation of the coverage booklet which many plans provide online as well!

What is the Annual Dedicated Amount? If your health plan has an annual deductible or out-of-pocket maximum, as most preferred provider organization (PPO) plans and even some HMOs do; then it may not have paid because you did not meet those costs in full. Find out if they’re based on when coverage began for example August 15th vs January 1st – there could be different requirements depending on which date the particular policy started with!

The first step in understanding your health care coverage is to review the information provided. You can find this detailed description of benefits on page two after signing up for an account, or by calling customer service and asking them about it over the phone! Your plan may be denying your claim because you haven’t met the costs of covered services. You can ask to discuss it over the phone, but if not- file an appeal or internal review with them!


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