Reasons behind Denial of Health Insurance Claim and the Options Available to You

Health Insurance Claim

There might be situations when your health insurance company can deny your claim and refuse to pay for some of your healthcare costs. Your insurance company can deny paying for a test, treatment, or procedure which either you have availed or seeking pre-authorization before receiving the healthcare service.


Reasons behind Health Insurance Companies Denying Claims

There are innumerable reasons for health insurance carriers may deny payments for a healthcare service, though some reasons are relatively simple and easy to fix whereas some reasons are difficult to address. Some of the reasons behind denial of health insurance claim include:

Mix-ups or errors in Paper

There is a chance of error in the claim paper, for instance, the doctor’s office submitted a claim for Peter S. Public, but the insurance company has listed the insured as Peter Q. Public. So, due to changes in name, the insurance company can deny coverage.

Doubts on medical necessity

Your insurance carrier might have doubt that your requested service is not medically necessary for you. The reason behind their thought maybe that you don’t need the requested service or you may need the service but you have not convinced your insurer that this service is essential for you. You along with your doctor need to inform your insurer that why the requested service is essential for you.

Cost Control

In order to control the healthcare cost, your insurer wants that you first opt for the less expensive option, and if it doesn’t work then opt the other options.

The Service is not Covered

You might have obtained medical service that is simply not covered by your health plan. Some of the services that are not covered under the health plan are cosmetic surgery or healthcare treatments that are not approved by the FDA. In case if you purchase a plan that is not regulated as per ACA rules like a short-term plan or fixed indemnity plan that doesn’t cover services like prescription drugs, mental health care, maternity care, etc. that are covered by the major plan.

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Provider Network Issues

You may be eligible to receive health care services provided by doctors and hospitals that are part of your plan’s network provider, as it might be the condition with your health plan. If you are receiving medical service from an out-of-network provider and seeking prior authorization, then your insurer might deny the authorization. In such circumstances, you will need to convince your insurance company that your chosen healthcare provider is only capable of providing this service. Sometimes, an insurer can make an exception and provide coverage but you should know that the difference between what your insurer pays and the amount that healthcare provider charge will be billed to you.

Missing Details

At times, the doctor’s office doesn’t send sufficient information with the claim or pre-authorization request. For instance, you have requested your foot MRI but the same information might not be shared by the doctor’s office, then your claim can be denied.

Health Plans’ Rules were not Followed by You

If your health plan requires you to get pre-authorization for a specific non-emergency test, but you get the test done without getting pre-authorization from your insurance carrier, then your insurer has the right to deny payment for that test, even if that test was essential for you. You will be denied coverage simply because you didn’t follow the rules of your health plan.

Your Options after Denial of Claim

If your health plan denies a claim for a medical service that you have already received or denied a pre-authorization request, then denial is irritating. However, denial not always implies that you are not allowed to have that specific medical service. Rather it means that your insurance company will not pay for the service, or you will require to appeal against the decision and if your appeal is successful, then you can be potentially covered. Some options that you can try after denial of your claim are discussed below:

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  • You can probably receive the health care service without any delay if you are willing to pay for the treatment yourself.
  • In case if you cannot afford to pay for the treatment yourself, or you don’t want to pay out-of-pocket, then you have to look for the denial cause and see if you can get it overturned. This is a process called appealing a denial and it can be done along with a prior authorization denial or the denial of a post-service claim.
  • All the healthcare plans have an appealing process for denials that are codified by the Affordable Care Act. These processes are outlined in the notification that you received stating that your claim or pre-authorization request has been denied. You are advised to carefully follow the appeal process and you should keep records of your every step, and if you are conversing on the telephone, then you should keep a record of the person with whom you spoke.
  • If it is not possible to internally resolve the issue, then you may request an external review of the denial carried out by a government agency or any neutral third-party.

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