Your people call us, not the carrier.
This is the part of the job employees actually see. A denial arrives, or a bill arrives that does not match what anyone was told, and somebody has to sit on hold with a claims department and argue a point of fact. When that somebody is your HR manager, the cost of the benefits program quietly includes their week.
Most denials are not coverage decisions. They are data problems wearing a coverage decision’s clothes.
A denial letter reads as final. Read the codes underneath it and a large share of them turn out to be something that can be corrected rather than argued, which is why the first step is always to find out what actually happened rather than to appeal immediately.
Coding and Billing Errors
A wrong procedure or diagnosis code, a missing modifier, a facility billing a service the carrier expected from a professional claim. Nothing about the coverage is in dispute — the claim simply does not describe what happened. The fix is a corrected claim from the provider’s billing office, not an appeal to the carrier. We identify the specific code or field that is wrong and ask for the resubmission, which is usually faster than any appeal.
Eligibility Mismatches
The carrier believes the employee or a dependent was not covered on the date of service, usually because an enrollment or termination file disagreed with payroll. This is the single most common denial we see, and it is fixed upstream rather than appealed.
Medical Necessity and Network
The genuine coverage disputes: a service the plan considers not medically necessary, a prior authorization that was never obtained, or an out-of-network provider inside an in-network facility. These are the ones that need a real appeal, with the plan document and the clinical record attached.
We take the file, not the phone number.
Forwarding an employee to the number on the back of the card is not advocacy. Your account manager and customer service seat take the case, find out what the claim actually says, and pursue it — with the employee told what is happening rather than left to guess.
We Read the Record First
Explanation of benefits, the provider bill and the plan language, side by side. An appeal written without all three is an opinion, and carriers answer opinions with form letters. Read together, they show whether the carrier applied the plan’s terms, whether the provider billed what was done, and whether the employee’s share was calculated correctly. That answer decides the next step: a corrected claim, a phone call or a formal appeal.
Appeals, Then the Next Level
Internal appeal with the clinical documentation attached, and where the plan and the law provide for it, independent external review after that. A first denial is a position, not a verdict. External review is decided by an independent organization rather than the carrier, and it works from the record built at the internal level. So we assemble that record from the start as if an outsider will read it.
Balance Bills
Federal surprise-billing protections changed what a provider may bill a member for emergency care and for out-of-network care delivered at an in-network facility. A bill that ignores those protections is challenged rather than paid. The first step is checking whether the service falls under those protections. If it does, the employee should owe only the in-network cost share, so we tell them not to pay while it is disputed and take it up with the provider and the carrier.
Employees ask benefits questions at inconvenient hours.
Around the Clock
Our chat access answers coverage questions at any hour and escalates to a person when it should. Most questions are not disputes — they are someone checking whether a visit is covered before they go, which is the cheapest moment to answer.
Off Your HR Desk
Employees contact us directly. Your HR team stops being the translation layer between a distressed employee and a claims department, and gets the week back. HR still hears about patterns, such as a recurring eligibility error or a provider that keeps billing incorrectly, so the cause gets fixed rather than handled one call at a time. Individual health details stay between the employee and us.
Reporting You Can Use
Claims, pharmacy and stop-loss data pulled into one report instead of three carrier logins, with high-cost outliers flagged before the renewal conversation rather than during it. For a fully insured group, the detail available depends on the carrier and the group’s size, so the report shows what the plan can produce. For a self-funded or level-funded group, it is also where large claims against stop-loss get tracked ahead of renewal.
What employees and HR ask about claims.
What can actually be appealed?
More than people expect. A large share of denials are coding, eligibility or coordination-of-benefits errors rather than coverage decisions, and those are fixed with a corrected record rather than an argument about medical necessity. Coordination of benefits is a typical case: the carrier holds a claim until the employee confirms whether a spouse’s plan pays first, and a short update releases it.
How long does an appeal take?
It depends whether the problem is data or judgment. A data error can turn quickly once the right record is in hand. A medical-necessity appeal runs on the plan’s own timetable, with a further level after that. For medical-necessity denials, federal rules set maximum decision times by claim type, with urgent care moving fastest. We file as soon as the record is complete.
Does our HR team have to be involved?
No, and that is the point. The employee contacts us directly and we take the file, so the problem does not sit on a desk that has no access to the claim detail anyway. The exception is an eligibility error, which is fixed in the enrollment record your team controls. We tell HR exactly what to change and confirm when the carrier has it.
Claims Advocacy in Bloomfield Hills When a Claim Goes Wrong
An employee gets a denied claim or a surprise bill. They bring it to HR, and HR spends hours on hold with the carrier. Claims advocacy in Bloomfield Hills gives your employees someone to call who knows how carriers work.
We are CFH Insurance Consultants, an independent benefits firm in business since 2007. No carrier owns us. We help employers and their employees in Bloomfield Hills, Birmingham, Troy, Southfield and across Michigan.
Claims Advocacy
Claims advocacy means we speak up for your employee with the carrier. The carrier or plan administrator still decides the claim. Our job is to find out what went wrong and make sure the right people hear the full story.
Here is how our claims advocacy in Bloomfield Hills works:
- The employee contacts our customer service team.
- We review the explanation of benefits, or EOB. That is the statement a carrier sends showing what it paid and why.
- We contact the carrier to find the cause, such as a coding error or a missing form.
- If the claim still stands, we help the employee file an appeal.
For proper coverage of an account we work in teams of 5, including customer service. A chat assistant also answers questions around the clock.
What should an employee do when a health claim is denied?
Do not ignore it, and do not pay right away. Follow these steps:
- Read the EOB and find the denial reason.
- Call the doctor’s office and ask if the claim was coded correctly.
- Ask the carrier what is needed to fix or reopen the claim.
- Write down each call: date, name and what was said.
- If the answer is still no, file a written appeal before the deadline.
Your plan documents list the appeal deadlines. Missing one can close the door, so act early.
Can HR see an employee’s medical claims?
Usually not. Privacy rules limit what an employer can see about an employee’s health care. That protects your people. It also means HR often cannot fix a claim problem alone.
That is one reason employees can come to us directly. They share what they choose with us, and we work with the carrier on their behalf.
Common questions
Does CFH decide or pay claims?
No. The carrier or plan administrator decides and pays claims. We push for a fair and correct answer. Our part is making sure the carrier decides on a correct record and the right plan terms, and that the employee knows their appeal rights and deadlines. On a self-funded plan, the employer’s role in appeals should be spelled out in the plan document.
What kinds of problems can you help with?
Denied claims, billing errors, surprise bills, network questions and ID card issues are common ones. Also coordination of benefits with a spouse’s plan, prior authorizations that were never filed, and prescriptions denied at the pharmacy counter. If it touches the plan, bring it to us first.
Can employees reach you after hours?
Yes. A chat assistant answers questions around the clock, and our customer service team follows up. The chat covers routine coverage questions, such as whether a visit or a drug is covered, and passes anything that needs a person, like a denied claim, to our customer service team.
Talk to us about claims advocacy in Bloomfield Hills
Book a 30-minute call or send us your renewal, and we will explain how your employees can reach us. Our office is at 41000 Woodward Avenue, Suite 350 East, Bloomfield Hills, MI 48304. Call 248.370.8853.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
An independent employee benefits consulting firm. We look at the entire benefits program — cost, plan performance, risk and administration.
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