Reducing the Chances of Denial of Your Texas Health Insurance Plans Claims

The first step to reducing your chances of having a Texas health insurance plans claim denied is to read your certificate of coverage carefully. It is important that you understand what services are included, and which are excluded. There may also be a waiting period for treatment of certain pre-existing medical conditions in effect, which would render medical care for these excluded also. There are also certain medical services that require pre-authorization. All of these things vary based on your particular Texas health insurance plans, so you need to be knowledgeable of your own particular exclusions, inclusions, and pre-authorization requirements.

One common situation that receives denials from Texas health insurance plans is receiving treatment that the carrier deems not medically necessary. The focus of your appeal process, therefore, needs to be explaining in detail why the procedure was medically necessary. You will probably need documentation from your physician, and perhaps additional medical professionals can also provide evidence to the appeals department of your from Texas health insurance plans demonstrating necessity. In one example, an adult received emergency medical treatment outside of the state, which resulted in its being outside the Texas health insurance plans network. The medical staff in this other state told the patient that he should not return to his home state before receiving treatment. Therefore, the patient requested the medical staff to provide documentation that they did not believe he would be safe to travel before receiving the recommended treatment. All of this documentation should be sent to the Texas health insurance plans’ claims department, perhaps even using certified mail to ensure delivery.

This situation, however, may have been avoided by calling up the customer service phone number printed on the back of the Texas health insurance plans member identification card, and letting them know that there has been an out of state emergency. At that time, the Texas health insurance plans representative can inform you of the proper procedure to use when out of state, or out of network. Emergencies receive certain allowances by most all Texas health insurance plans, and some requirements are waived, such as pre-authorization or notice given, due to the extenuating circumstances.

Another way of reducing your chances of a denial is to call your from Texas health insurance plans ahead of time to check on your benefits. You can check on included and excluded services before receiving medical care by calling up your Texas health insurance plans customer service 800- phone number, or by checking on the company’s web site. Many Texas health insurance plans have a members only confidential section on their web site where you can review your benefits, and find an in network physician, etc. You can also request pre-authorization of certain services, such as behavioral care, from the web site, in many cases.

If you do have to appeal a deal, however, the Texas health insurance plans claims department will usually respond to an appeal within a few months. If they reverse their denial, they will then pay out benefits as agreed upon. If they deny again, then you may appeal more times, depending on your Texas health insurance plans appeal policy. Some states have external review boards that you can appeal to. This board will probably be made up of medical professionals who will review your case.