My health insurance..... told me i wasnt sick enough??

so here's my story..... i needed to go to the emergency room the other night. it was about 12am. and you know where else are you going to go when you need medical attention right away. and know my insurance tells me that it wasnt an emergency and i wasnt sick enough to go.... so they arent going to pay the bill, is there anything i can do??
Additional Details
so i had a kidney infection.... and basically my policy states an emergency as something that can severely impact bodily functions. i thought i was pretty sick. and the doctor told me that if i hadnt been so well hydrated that they would of admitted to into the hospital so it's not like it wasnt serious. i didnt go there because i had a cold....

Your insurance company determines whether an ER visit is an emergency based on the primary diagnosis submitted on the claim.

A hospital claim form (UB-92) can have multiple diagnosis codes (ICD-9 codes) listed, but one will be listed as the primary reason for your visit.

The insurer's claims processing system is programmed to recognize each diagnosis code as "emergency" or "non-emergency." If the diagnosis code on an ER visit is labeled "non-emergency," then the claim will be denied.

What does this mean to you? Well, obviously the primary diagnosis code on your claim was recognized as "non-emergency." This means one of 2 scenarios occurred here:

1) The diagnosis code submitted was incorrect, and the hospital billing people will need to re-submit a corrected diagnosis.

OR

2) The correct diagnosis was submitted, but the insurer does not consider your situation a medical emergency.

If the 2nd situation applies, the appropriate way to appeal the decision would be to submit a copy of the medical records from your ER visit. The chart notes will assist the insurer in determining the nature of your visit.

Keep in mind that the insurer will consider other things in addition to the severity of your symptoms.

For example, they'll consider the onset of the symptoms. If its documented in your medical records that your symptoms began several days before your ER visit, the insurer will (correctly) state that going to the ER was not necessary. You could have went to a regular doctor or clinic some time after the symptoms began, rather than waiting several days to go to the ER. (note - this is just one example of a reason why an insurer could label an ER visit as non-emergency, not trying to say that's what happened in your case of course.)

Anyhow, that's how you can attempt to get the insurer to pay the bill. Either submit the medical records for appeal/review, or the hospital could re-submit a claim with a corrected diagnosis code (if applicable - they can only do this if there was a coding error on the original claim).

If the insurer reviews the medical records and still says it wasn't an emergency, they should at least be able to give you a specific reason why. If you still disagree with that decision, you should have second level appeal rights and/or the right to have an independent medical review board look at the documentation.

In a nutshell, that's how you do it.

Check the insurance policy. There must be an appeal process. Follow their procedure and file an appeal.

If your policy states that there are instances that won't cover ER visits, like hangnails for example, and you choose to go, then you will be responsible for the bill.

Sorry.

You should appeal this to your insurer in writing. Attach a copy of the medical records made during your ER visit and ask them to reverse their decision. If they uphold their determination, send a written complaint to your state's insurance commissioner's office and ask them to look into it.

Insurance companies do that because so many people use ERs as urgent care clinics when its not really an emergency. You can try their appeal process, but you'll have to justify why you thought it was an emergency that couldn't wait for an urgent care clinic (or regular office) visit.

Ask the hospital to reprice to a cash price, and pay the bill.

You can contest it, but winning is going to depend on what was wrong. If it was a cold, you're not going to win.

Normally, health plans DO cover, subject to a big fat deductible, if you go to the emergency room. They waive that deductible if you're sick enough to get admitted.

You would have to provide medical documentation to the ins co that it seeking medical treatment at that time in the ER was medically necessary, and to delay would have resulted in a serious risk to your health.
You have to convince the ins dept that this couldn't wait until you could make an appt with your primarycare provider. Unfortunately, unless you have a temp of 106 degrees or were just run over by a cement truck, this can be very difficult.
Call the hospital and ask for the billing dept.

Simple solution... Move here to Canada!

All health care= free

I had an ingrown toenail once and they took care of it. It WAS pretty bad though i guess, but same idea. Nobody has to pay for ANYTHING accept for some prescriptions, but you can get covered for that too, oh, and you have to pay for elective things like breast implants, but thats ovious!

Lol, sorry I'm no help

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