Billed
The amount your therapist charged.
APPEALS
A denial is a reason to read, not a reason to quit.
Start with the EOB, find the reason, decide whether the claim needs a correction or an appeal, and keep every date.
READ THE EOB
The plan's math, in plain words.
An explanation of benefits, or EOB, is the plan's record of how it handled the claim. It is not a bill.
Allowed
The amount the plan uses for its calculation.
Deductible
The allowed amount applied before the plan starts sharing the cost.
Coinsurance
The share the plan assigns to you after the deductible rules are applied.
Plan paid
The amount the plan says it paid.
Your responsibility
The amount the EOB assigns to you under the plan calculation.
THE REASON
Find the denial code.
A denial code is the short label the plan uses for why it did not pay the claim as submitted. Read the code beside the full explanation on the EOB. Keep both with the claim packet.
Correction or appeal
A correction fixes something incomplete or wrong in the submitted packet. An appeal argues that the plan should change its decision based on the claim, the plan terms and the records you provide. Read the denial reason before choosing the path.
THE CLOCKS
Write down every deadline.
Employer plans give you at least 180 days to appeal (29 CFR 2560.503-1(h)(3)(i)).
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The plan has 30 days to decide a post-service claim ((f)(2)(iii)(B)) and 60 days to decide your appeal ((i)(2)(iii)(A)).
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You may ask for your claim file free of charge ((h)(2)(iii)).
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After the internal appeal you may request external review within four months (45 CFR 147.136(d)(2)(i)).
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The reviewer decides within 45 days ((d)(2)(iii)(B)(6)) and the decision binds the plan ((d)(2)(iii)(B)(7)(v)).
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ANOTHER RUNG
The state regulator.
If the review process still does not resolve the claim, your state insurance regulator is another rung. Use the regulator named in your plan materials or ask the regulator how to send a complaint. Keep the EOB, letters, dates and proof of submission together.
Prepare my appeal
The skill's appeal routine drafts the letter from your records.