Secondary Out-of-Network Health Insurance Claims: The Challenge of Navigating Denied Claims

Dealing with health insurance can be a complex and frustrating process, especially when it comes to secondary out-of-network claims. If you’re facing denied claims without a clear reason, you’re not alone. Many individuals have encountered this issue, leaving them wondering why their claims are being rejected.

Understanding Secondary Insurance Coverage

Secondary insurance is designed to provide additional coverage when your primary insurance has reached its limits or doesn’t cover certain expenses. It’s important to understand that secondary insurance is not meant to fully cover your healthcare costs; instead, it supplements your primary coverage by paying a portion of the remaining balance.

Common Reasons for Denied Secondary Claims

1. Missing or Incorrect Primary Explanation of Benefits (EOB): Your secondary insurance company requires a copy of your primary EOB to process your claim. This document provides details about the services you received, the dates, and the amount your primary insurance covered. Even if you think you’ve submitted the EOB, it’s worth double-checking to make sure it’s complete and accurate.

2. Out-of-Network Provider Restrictions: Out-of-network providers are not contracted with your insurance company, which means they don’t have to accept the same rates. As a result, your secondary insurance may deem the charges to be excessive or not medically necessary, leading to a denied claim.

3. Deductible and Coinsurance Not Met: Before your secondary insurance kicks in, you may need to meet your primary deductible and/or coinsurance. If you haven’t met these requirements, your secondary insurance may deny your claim.

4. Claims Processing Errors: Sometimes, denied claims can be simply a result of human error or technical glitches during the claims processing process. It’s important to follow up with your insurance company to ensure that your claim was handled correctly.

What to Do When Your Claim is Denied

If your secondary insurance claim is denied, don’t give up. Here are some steps you can take:

1. Review the Denial Letter Carefully: Read the denial letter thoroughly to understand the specific reason for the rejection. This will help you determine the next steps you need to take.

2. Contact Your Insurance Company: Call your insurance company and speak to a customer service representative. Explain the situation and provide any additional documentation that may be needed, such as an updated EOB or proof of your out-of-network provider’s charges.

3. File an Appeal: If you believe your claim was wrongfully denied, you have the right to file an appeal. The appeals process involves submitting additional evidence and documentation to support your claim.

4. Consider Bad Faith Claims Denial: In some cases, insurance companies may intentionally deny claims without a legitimate reason. If you suspect bad faith, you can report the company to your state’s insurance regulator.

Seeking Professional Help

Navigating secondary insurance claims can be challenging, especially when you’re dealing with denied claims. It’s recommended to seek the help of a licensed insurance agent who can guide you through the process, help you understand your coverage, and assist you with any appeals or disputes.