April 26, 2024

External Insurance Reviews Provide Hope

Denied health care claims have, unfortunately, become commonplace, both in Oklahoma and across the country. In a never-ending effort to remain profitable, health insurance companies regularly delay, underpay, and outright deny claims, leaving individual policyholders unable to get the treatment they need or saddled with astronomical medical bills.

If your health insurance claim has been denied it is important to recognize that the decision may not be final and that you do have recourse.

The processes for internal appeals and external reviews can be complex. Insurance companies engage teams of individuals, including legal professionals, to minimize their expenses by defending their actions.

If you are struggling with inappropriately paid claims, engaging legal representation from a denied health insurance claims lawyer in Oklahoma can increase your chances of obtaining the reimbursement to which you are entitled. Experienced professionals know how to respond and address these issues effectively.

Control What You Can

Have you exhausted your appeals with your insurance company, yet still not reached an acceptable resolution? If so, it may be time to embark upon an external review of your denied health insurance claim.  At this point in time, you cannot control their responses, but you can manage your actions.

External reviews are completed through the Oklahoma Insurance Department (OID). This organization requires a specific process to be followed for them to examine your case.  Completing the steps below is important as you move forward with your attempt to have your health insurance claim paid appropriately. The process can be time-consuming; the paperwork is significant, and completing and submitting it correctly can be challenging.  The assistance of an Oklahoma denied health insurance claims attorney can relieve you of much of the stress associated with the process and help to ensure everything is submitted in compliance with the department’s rules and regulations.  Consider what must be done:

Confirm Eligibility for External Review

The nature of your denial determines whether your claim is eligible for an external review.  If your claim was denied because of questions regarding medical necessity, appropriate treatment, treatment location, and care and effectiveness (including experimental treatments) the OID should accept your request.

Unfortunately, while many claim review requests will be accommodated, some are not eligible. For example, denial for benefits not covered by your policy will not be reviewed, regardless of their medical necessity.  And administrative error denials, like late premium payments, will not be reexamined.

Finally, if you have your health insurance through a federal plan like Medicaid and Medicare or if your employer self-funds their insurance plan, this specific process is not available to you; you must leverage a separate appeals system.

Gather Documents

Submitting a complete application for review, including the right documentation, is critical. You want to gather all relevant paperwork to share with the department.  These include, but are not limited to:

  • Health records from all treating physicians, making sure they include dates of treatment
  • Copies of the claim forms submitted by your provider or by you
  • Copies of the initial denial notifications
  • A copy of your health insurance policy
  • Letter from your physician stating the health issue, appropriate treatment, and request for coverage
  • Documentation of medical and scientific research that can be used as evidence of medical necessity and success
  • Copy of your internal review letter submitted to the insurance company and their response.

You must ensure that you provide all information that can support your case at once, along with your request for review. A health care claims denial attorney can help determine exactly what to submit in each specific case and ensure the information is provided in a clear and easy-to-access manner.

Choose Your Review Method

If your internal review with your insurance company was unsuccessful, you may escalate your issues through the external review process. It is important to understand that timing is critical to this decision. You only have four months from your insurance company’s decision to request an external review by an Independent Review Organization (IRO) – an accounting, law, or consulting firm.  The organization must be independent of both you and your insurance company and possess the national certification issued by the OID.

IROs are assigned randomly; once your case is approved, they have up to 45 days to conduct their review and make a final, binding decision.

For those in need of urgent medical care, expedited processes are available. It is important to recognize that all IRO costs are assigned to your insurance company; you have no financial risk in requesting the review.

Complete the Application

To move forward with an external review you must accurately complete and submit the required application. This multi-page document requires a great deal of information, including documentation from your physician.  You want to answer all the questions to maximize your chance of a successful appeal.

Once finished,  you should attach all supporting documentation, make a copy for your records, and submit it to the Oklahoma Insurance Department.

Where You Can Get Help

Doug Terry Law Provides Hands-On Assistance

While the Oklahoma Insurance Department does have a contact line for questions regarding the completion of their application, it may be in your best interests to engage the guidance of an experienced denied claims attorney.  You are likely overwhelmed, and the process is both time-consuming and complex.

Doug Terry founded his firm on the belief that individuals in Oklahoma deserve the same quality representation as their insurance companies. His firm is dedicated to pursuing settlements for those whose claims have been unfairly underpaid, delayed, or denied. He and his team have decades of proven experience helping clients address their denied health care claims. They understand how to approach external reviews and are eager to help you.

Reach out to them today at 405-463-6362 to schedule a free consultation to understand how he can help with your external review of your denied health insurance claim in Oklahoma.

Attorney Doug Terry

Attorney Doug TerryAfter 25 years practicing in a larger firm, Doug chose to open his own practice in Oklahoma City. He brings his wealth of knowledge and his skills as a litigator to bear for his clients in matters of insurance bad faith, personal injury cases and class actions. He won $200 million and $25 million verdicts for clients in cases in which an insurer denied a health insurance claim. Doug has the distinction of being awarded a Martindale-Hubbell “AV Preeminent” rating from his peers in the legal community. He has also been selected as an Oklahoma Super Lawyer. [Attorney Bio]