By Thomas Vincz, Public Relations Manager

In life, we learn quickly to expect the unexpected. That’s a big reason why we buy health insurance. But, what if your policy doesn’t cover something you expected it to and you need to file an appeal?

Fortunately, that’s a rare event. But it does happen — in 2018, of the 60 million claims filed with Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ), just 8,438 were appealed. Still, if it happens to you, it’s a big deal.

The appeals process is there to make sure that coverage decisions are based on the facts – facts about your specific insurance policy, your claim and the current medical evidence and standards.

Understanding when to appeal

There are rare instances when a claim is declined due to an error, mistake or omission that could be on the part of the insurer, the doctor or the policyholder. Below are two examples that differentiate between a claim denial due to a mistake — which can be appealed — versus one denied because your health insurance plan does not include coverage for that particular service. Those denials are, generally speaking, not appealable.

You can appeal an incomplete claim

A request for a pre-authorization for a medical procedure may get declined, but not because your benefits don’t cover it. It may be because your doctor’s office inadvertently excluded a page or other piece of documentation when submitting the request. For some procedures, health insurers require information to establish “medical necessity” — records demonstrating that the test or procedure is appropriate and meets the standards of care established by the independent medical organizations that insurers rely on for their medical policy.

Out of policy

By signing into your Member Online Services account, you can learn what’s covered and what’s not, and better avoid claim denials.

Insurance policies can be complicated. For instance, a service may be covered under some circumstances, but not others. For example, let’s say you have shoulder pain and go to a massage therapist because you know physical therapy is covered. While the massage is a covered benefit, it is likely only covered when the service is administered by a licensed physical therapist, but not when administered by a massage therapist. And therein lies the rub, so to speak. The claim denial should be appealed if the massage was administered by a physical therapist. If the massage was administered by a masseuse the appeal would not be approved. (Now you know why massage therapy vs. physical therapy is one of the more common forms of Horizon claim disputes).

Before jumping into the appeals process, take a minute to check with the terms of your policy on the Member Portal (horizonblue.com). If you are still not sure, contact us — or, if you get your coverage through your employer, speak with the company’s health benefits administrator. To reach Horizon, use the online chat feature, submit your question through email or give customer service a call. Understanding the specifics of your policy’s coverage and reimbursement parameters is the best way to avoid confusion, unnecessary appeals or a bill you weren’t expecting.

Types of appeals

If a claim is denied for what a member or provider believes is missing information or a simple mistake, there are generally two appeal options: Administrative and Medical. It is important to know the distinctions. It’s also important to remember that Horizon BCBSNJ wants to help you get the most out of your benefits and will help guide you through the appeals process. We know that it can be frustrating and we’re committed to working with you every step of the way until the situation is resolved.

ADMINISTRATIVE APPEALS

What it is

Routine matters that involve insurance policy contract claims, such as what is covered, benefits, how much your policy allows for co-payments and other out-of-pocket costs.

Why administrative claims can be declined

Just like any contract, the terms of your insurance contract (policy) specify the breadth, and limitation, of your coverage. Administrative claims may be declined because of language in the insurance policy.

How to resolve it

1. Contact Horizon BCBSNJ: Most of these appeals are resolved on the spot by contacting a customer support representative by phone, email, chat or US mail.
2. Initiate a formal appeal: If the appeal is not resolved to your satisfaction, you may initiate a formal appeals process. A nine-member Members Appeals Committee – Benefit Issues and Complaints (MAC-BIC), comprised of consumer advocates and Horizon representatives, meets weekly to consider appeals. After reviewing your case and all of the records and evidence provided by you or your doctor, you will be notified of the decision and rationale within 24 hours. Forms for this process can be found on HorizonBlue.com.

MEDICAL APPEALS
 

What it is

These types of claims typically involve procedures that your doctors or others on your care team are asking Horizon BCBSNJ to “pre-authorize” as being covered for reimbursement. It includes claims for medical services initially found to be:

• Not consistent with medical policy; 
• Considered as investigational or experimental; and/or
• Not medically necessary.

Why medical claims can be declined

A doctor must submit a pre-authorization request. If the doctor’s recommended procedure, drug or other remedy for a patient deviates from medical norms, peer-reviewed case studies and other documented evidence, it is considered experimental or investigational and not eligible for coverage.

How to resolve it

1. Initial appeal: If a doctor’s pre-authorization request is denied, the member and their doctor are notified and advised how to appeal. It is the member’s responsibility to appeal, but they do so in consultation with their doctor. When the evidence is gathered, the decision is rendered.
2. Appeal to Horizon BCBSNJ Member Appeals Committee (MAC): If that decision is not in the member’s favor, the members and their physicians can make an additional (“second level”) appeal to the Horizon BCBSNJ MAC.
3. Appeal to an independent review: If Horizon BCBSNJ MAC does not decide in the member’s favor, the final option is to bring the case to the Independent Utilization Review Organization (IURO) retained by the New Jersey Department of Banking and Insurance. IURO decisions are final and binding.

Whether patient, doctor, specialist or insurer, all parties have rights and responsibilities in the insurance process. The appeals structure is a system of checks and balances that helps to ensure everyone is treated fairly, and the health care system is managed properly.

Appeal rights, levels, and filing deadlines, may vary by health plan. For specific information on your right to appeal a claim denial, please review your official plan documents.