A health insurance claim can be denied for a few reasons. It happens when the insurance company refuses to pay for a service you may receive. If it happens after you have already had treatment and the claim has been submitted then it’s called a claim denial. Sometimes an insurer will say ahead of time that they won’t cover a particular service. This happens during the pre-authorization process and it’s known as prior authorization or pre-authorization denial. In both of these cases, you are able to appeal and possibly get the insurer to reverse the decision and agree to pay for your services.
The Claim Has Errors
Data errors are the most common reason why a claim may be denied. Sometimes a provider may code it wrong, have your birthdate wrong, misspell your name, or leave out some information. Your explanation of benefits can give you some clues as to if your claim had any errors, so check there first. If you do find an error, have your provider correct the information and resubmit the claim.
You Used a Provider Not In Your Health Plan Network
Many health plans only cover care if you use facilities or providers in a specific network. If you go out of the network then the plan may not cover any of the cost. Some plans may cover some of the cost of any out-of-network care, but you then have to make up the difference.
Your Provider Should Have Gotten Pre-Approval
Some procedures, such as an MRI, CT scan, or some surgeries, require pre-authorization. If you have a claim denied because it wasn’t pre-authorized then you should speak with the medical professional who ordered the procedure. There may be something he or she can do, such as show patient records that demonstrate you needed the service. If you are trying to get prior authorization for a service that is performed by an out-of-network provider then you may get denied the authorization, but you can get approved if you choose a different healthcare provider.
You Received Care That Isn’t Covered
Sometimes care is not in your health plan. For example, weight loss surgery may not be covered in your health plan. If that is the case then it doesn’t undergo medical review, and if the plan doesn’t cover it then the claim won’t be approved. This is called contract exclusion or coverage limit. If you have lost health coverage then your claim may also be denied. This can happen if you don’t pay your premiums. Sometimes claims can still be denied for medical reasons. This can happen if you got services that weren’t medically necessary, the setting for your care isn’t at the right level, or the treatment that has been given is considered experimental or hasn’t been proven effective for your condition. Sometimes an insurer may want you to try a less expensive or different option first. If this is the case then the requested service will be denied unless you try the less expensive option first. If you try out the least expensive option and it doesn’t work then your claim is more likely to be approved.
The Claim Goes to the Wrong Insurance Company
This can happen if you have coverage under two health plans. For example, if you have coverage under your employer and also your spouse’s employer then the provider may have billed the wrong company. It can also happen if the provider has incorrect information for your plan or if you change insurers. When you get your explanation of benefits, make sure it’s from the right health plan and then be sure to contact your provider in order to prevent this from happening.
What Should You Do about Health Insurance Claim Denial?
Whether you are denied a pre-authorization or a claim for treatment you already got, getting denied is frustrating. A denial doesn’t necessarily mean that you can’t have that particular service, instead, it means that your insurer won’t pay for it or you need to appeal the decision to have it potentially covered. If you are willing to pay for treatment out-of-pocket then you can move forward with the treatment without any delays. If you don’t want to pay out-of-pocket or can’t afford it then you will need to look into the cause of the claim being denied and see if you are able to get it overturned. It’s important to follow the appeals process carefully. You want to keep good records of every step you take, when you take them, and who you speak with. In many cases, the provider’s office will be involved in the process too and will handle a lot of the documentation that will be sent to the insurer.
An appeal letter may be required with information your insurance company tells you is needed. It should include an opening statement about what service was denied and the reason for denial. You will then explain your health problems and medical history and why you believe the treatment is medically necessary. You can list treatments you have already tried and explain why the current treatment is necessary for your condition. Getting a doctor to support you is important. If treatment is new then you will need documentation from recognized institutions, such as medical schools or hospitals, to show it’s part of a treatment plan. The appeal should be sent by certified mail so you have proof you submitted it within the time limits. If appeals are only accepted online then keep records of the emails sent.