Kajko, Weisman & Colasanti, LLP

What documents should you have for a health insurance dispute?

One of the initial steps to appealing a rejected claim by your Massachusetts healthcare insurer is to file an internal appeal with the insurer. At this stage, you are appealing the decision to reject your claim with the company itself and are not seeking outside intervention. To assist your chances of prevailing in your appeal, Healthcare.gov details certain documents you should gather.

First, you need to show the insurer in documented form what you have been denied. This can be found in the Explanation of Benefits papers that your insurer provided. You would look for the section that explains either the payment that the insurer offered or the services that the insurer would provide. Additionally, you should keep copies of the internal review request that you sent your insurer.

You must also keep copies of all the relevant medical information that relates to your condition. Perhaps your doctor wrote you a letter, or has provided treatment information such as the procedure required to handle your current condition. Your insurer may need this information for the internal review process, but you should maintain copies of it as well.

Additionally, it is important to document details about your phone conversations with your doctor or your insurer that involve appealing your claim. Write down the day and the time the conversation took place. Also include the name of the person you speak to as well as the individual's professional title. When speaking on a phone, have a notepad and pen handy to write down the important details of the conservation.

Finally, if your claim is urgent, you can also file for an external review even if you have not completed your internal appeal process. In the event your medical condition could seriously deteriorate in the next few days without the claim being honored, you can file for an internal and external review simultaneously and receive a response much more quickly.

This article is intended to educate readers on health insurance disputes and should not be taken as legal advice.

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