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Health Insurance Revision Webpage List



Date: 4/24/2017 Added:

Health Insurance Rejection of Claim

When a claim is filed, your insurance company will send back information entitled “Explanation of Benefits” (EOB) or “Explanation of Coverage” (EOC). This document will explain whether your claim is denied or accepted. Either way it should explain what is paid out by the insurance company, what you owe as “copay amount”, and what was “applied to deductible”. In this document it should have instructions as to how to dispute any part of the claim.

Your first appeal is to the insurance company itself. You should file the appeal in writing unless the appeal is urgent i.e. your health may be in jeopardy. The EOB or EOC will tell you the address to which you should send your appeal. It should also tell you what to include in your appeal. You should be as detailed as possible in your appeal.

In all states, you have to file a complaint with your insurance company before you can file a complaint with the agency in charge of oversight of your health coverage. You can file a complaint if you have received an unsatisfactory reply back, you have waited over 30 days from filing the complaint, or your need is urgent because of a health situation. The “Explanation of Benefits” (EOB) or “Explanation of Coverage” (EOC) will state what government agency regulates your health insurance and how to file a complaint with them.

Department of Managed Health Care (DMHC) https://www.dmhc.ca.gov/FileaComplaint.aspx and the California Department of Insurance (CDI) http://www.insurance.ca.gov/01-consumers/101-help/ regulates Covered California health plans. At this time the DMHC regulates the vast majority of Covered California Health Plans. If you contact the DMHC and they find that your health plan is under the jurisdiction of CDI, they will help you contact the CDI. Many states have insurance commissioners or departments of insurance and it is good place to start.

If your health insurance is from an employer self-funded health insurance or disability benefits either in current employment or retirement then it is regulated by the Employee Benefits Security Administration, US Department of Labor. Information on claim filing can be found here: https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-health-or-disability-benefits

What the Employee Benefits Security Administration does https://www.dol.gov/agencies/ebsa/about-ebsa/about-us/what-we-do#section4

If your employer is based out of state or has aggregated with other employers to purchase an out-of-state plan, you may have a health insurance plan that is regulated by another state and will have to contact that state’s insurance regulatory agency or commissioner.

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