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What to Do if Your Insurance Claim Is Denied

  • Category: Affordability
  • Posted On:
  • Written By: Atlanta Center for Reproductive Medicine
What to Do if Your Insurance Claim Is Denied

Knowing what your infertility benefits are isn't enough. You need to ensure you're receiving the benefit you're entitled to.

Every claim will generate an "Explanation of Benefits" from your insurance company. In most cases, your "EOB" should be available online. If you can't access it, call your insurance company and ask for one to be mailed to you.

Your EOB details exactly how your insurance company processed your claim. It will let you know what was paid to the doctor by your insurance and how much you owe (patient responsibility) if anything.

It's important for you, as the consumer, to understand how the insurance company processes your claims (either pay or not pay). They look at:

If you think your provider may have made an error in the information submitted to the insurance company, your best avenue for resolution is to contact your nurse and verify that the clinical information submitted is correct. If an error was made, please ask that a corrected claim be submitted. If not, then no change in coding is in order.

If you believe your claim was processed incorrectly, you should appeal the decision. Be sure you have the following information as you get ready to file your appeal:

  • The reason for the denial. The specific provision in your policy that excludes this treatment should be cited in the explanation of benefits (EOB).
  • The process (required by your plan) to be followed in filing an appeal. Normally, this process will need to be followed to the letter.
  • The name and phone number of a contact person at your insurance company. Your health plan administrator should be able to give you the name of the appropriate person to contact.

When you contact your insurance company, let them know you're calling about a claim that you believe was processed incorrectly. Always get the representative's name and a call reference number (if available). Should you need to make several appeals, this documentation will prove to be very helpful.

At ACRM, our patient account representatives are always available and happy to assist our patients with understanding their benefits and how their claims are processed.