Confessions of a Claim Adjuster
–By Sushma Pradhan
Are you in trouble with your claims? Is your claim taking a toll on you? If you agree to it, be sure you have hit the right site and you are reading the right article.
There is no doubt that resolving a claim or its adjustment is a long and a difficult process, but trust me it is not an impossible task at all.
Here are few steps that you need to follow, when you need to adjust a claim so that you maximize your effort of success.
Step One: Take out the statement document of your insurance coverage.
Step Two: Focus on the exclusions sections and read out everything carefully.
Step Three: If you find out that a certain point relates for the denial of your claim, be it even remotely, make it a point to highlight it.
Step Four: Put together all the claim denial notices and all the important statements, such as notes, documentation etc. Then, circle the invoice number dates, and reference numbers.
Step Five: Armed with all the documents call the customer care department of your related grievance.
Step Six: Speak confidently but do not be rude, while asserting why you feel that the claim should be granted.
Step Seven: Keep a note of all your calls, for example the time, the date, the full name of the representative of the company, with whom you had the conversation, the extensions, and the outcome of the conversations.
Step Eight: One more point that you have to keep in mind is the punctuality of follow up. When you speak to the customer representative, do make it a point to ask the representative for the date by which the claim will be resolved, and patiently wait until that date. In case the resolution has not occurred by the assigned date, do call up the representative by that date.
Step Nine: Once your claim has been paid or settled make sure the settlement is as per terms, in case it is a settlement for some amount of money do check that the company pays the stipulated amount or percentage.
Explanations
On a whole, there are certain things that we tend to overlook initially and many a times these points become the loopholes for us. Review the rules that are there in the document. There may be certain point that we may assume as clear, but later this ambiguity may be troublesome. In case, you find difficulty understanding a point and you do not find the answer in the provided literature or on their website, take out time to call the customer service.
Take for example you are looking for a health insurance claim. If your claim is not paid in full or is denied, whereas you think that it should not have happened so. Call the health plan for justification, the denial could be due to some administrative error.
Do remember to place all the paperwork in front of you when you make that call. However, remember to be polite, but reasonable. Do not use authoritative tone, your voice should convey the message that the two of you are enough to resolve the problem.
Further, you must also know when to request for a formal review. In case the customer service is of a little help to you, you may go ahead and file an appeal to the health plan. In many cases, you may need to do the writing within sixty days of receipt of all the original benefits explanation. Nevertheless, remember to send your appeal only via a certified mail.
Carefully examine all your documents. If you have made a determination for a formal review, there may be a chance of your gaining access to documentation that is necessary to determine the benefits.
Here are Tips and Warning once again:
1. Carefully read the explanation of the claim denial. Reading the document carefully throws a lot of light on where the loophole lies. You never know the required professionals must have failed to provide the necessary detail to the insurance company. If it is so then call the concerned authorities.
2. Know what you are speaking and yes know it well. Do not blabber. If you exhibit a complete knowledge about the coverage, you will get every chance of more attention from the representative of the company.
3. Yes! Start early in the day, if you feel that your calls are left on a hold for a long period.
4. Mind your language! Do not unnecessarily be rude to the service representatives of the company, after all they are not the ones who make rules for the denial of the claim.
5. Be firm and persistent in your resolution to reach a solution. See that the claim is either paid or provided with a proper explanation and furthermore, let everything come in writing, especially if the claim is not payable.
6. You may ask to direct your claim to a supervising claim adjuster for further consideration, if you feel that your claim is a exceptional case or needs more consideration than the customer service representative in the frontline.
7. It is vital to document all your calls as this will help you later a lot in resolving the claim dispute.
8. If your claim is for health insurance, make it a point to talk to your physician. Ask the physician to help you resolve the claim if the denial uses the terms such as ‘unconventional’ or ‘nontraditional’ or ‘unconventional’ for justification.
9. New procedures and coverages are updated, especially those of the treatments and medication, so do not get upset and lose hope at one go when your claim is not adjusted initially.
10. Do not lose your cool, most importantly do not lose your temper, neither shout nor lecture on the way the things should have been, while conversing with the service representative of the company.
11. If the company tells you that something that was covered earlier is no longer covered now, do not accept until and unless there is a logical explanation. If needed try to acquire the explanation in writing.
12. Remember slow and steady wins the race. Many insurance providers wait until the time you give up after fighting for a long time. So understand the twist of the story and be persistent.
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