Common Reasons for IEHP Denials and How to Address Them
You and your family may have been counting on the Inland Empire Health Plan to cover your health insurance claim, only to be disappointed when it was denied. If that is the case, the Inland Empire health insurance claims attorneys at Quincey Law can help.
IEHP has the obligation to follow California law when they are processing and responding to your health insurance claim. They cannot wrongfully deny it, or use any other tactics that rise to the level of bad faith. If they do, you can take various legal steps that can include seeking to force them to cover the claim or filing a bad faith lawsuit.
At Quincey Law, our job is to fight to ensure that you get a fair shake and that large companies cannot compromise your legal rights. Contact us today to schedule a free initial consultation with a health insurance claims denial lawyer.
IEHP Coverage Is Not an Assurance That Your Claim Will Be Paid
IEFP is a health plan that is tailored to low-income and working families. It is one of the largest Medicaid health plans in the country. However, IEHP is not always there for you when you need them. Many claims are denied, and you cannot receive the health benefits that you need. You can fight when IEHP has denied your claim, and even possibly file a lawsuit against them.
2024 marked IEHP’s first year as a part of Covered California, so there are no available statistics yet on the percentage of claims that are denied. Nationally, the rate of denials of pre-authorizations in Medicaid managed plans hovers roughly around the 13% mark.
Why IEHP Denies Health Insurance Claims
IEHP may deny your claim for a number of reasons, including the following:
- Eligibility: The member was not eligible for services on the date that the claim was filed.
- Uncovered Services: Like any other health insurance plan, IEHP states the services that they will cover in your plan documents. IEHP may believe that the care that you are seeking is not covered by your plan.
- Medical Necessity: IEHP may believe that the care you are seeking is not medically necessary, and thus, should not be covered
- Lack of Pre-Authorization: The medical care may have been given without the proper pre-authorization from IEHP.
- Out-of-Network Services: Services were provided by non-network providers without an appropriate referral or authorization
Regardless of whether and how much you have paid for your health insurance plan, you always have legal rights. It does not matter whether and how much you paid for your health insurance. The insurance company still must follow California law when it comes to processing and handling your claim. They must act in good faith, and they are prohibited from engaging in certain practices that may include:
- Denying a valid claim without a proper investigation
- Misrepresenting the terms of your policy
- Unreasonably delaying a decision on your claim
- Using tactics to delay, such as repeatedly requesting unnecessary documents
What You Can Do When IEHP Has Denied Your Claim
If you believe that IEHP has wrongfully denied your claim and has broken the law, you can take legal action against them. The first step that you should take is to contact an Inland Empire health insurance claims denial attorney to assess your legal options. They can advise you whether IEHP has wrongfully denied your claim and whether you have the ability and right to take legal action.
Then, you can fight to force them to cover your claim, as IEHP does not get the final say about whether they will approve your care. You may go through their internal appeals process, although insurance companies rarely reverse an initial denial of your claim. You can also file a complaint with the California Department of Managed Health Care. They may force the insurance company to cover the claim, but it would take time, and you would not be able to obtain damages from the insurance company.
IEHP is subject to California insurance bad faith law. You may even file a lawsuit directly against IEHP, seeking money from them for the damages that their wrongful denial has caused you when it was in bad faith. It is not always easy to prove that an insurance company acted in bad faith. Nonetheless, these lawsuits strike fear in the hearts of insurance companies because they can be ordered to pay you damages.
Contact an Inland Empire Health Insurance Claims Denial Law Firm Today
If IEHP has wrongfully denied your claim, reach out to an Inland Empire health insurance claims denial attorney at Quincey Law today. You can speak with an attorney by messaging us through our website or by calling us today at (866) 945-9175.
Nicholas Quincey is the founder of Quincey Law, and has over a decade of experience of handling insurance claims denials and personal injury matters for people throughout California. We have pursued insurance bad faith claims for people involving life insurance, health insurance, homeowners and disability insurance. We also work with clients and families who need assistance filing and pursuing a personal injury matter. Learn more here.