When your health insurance company refuses to pay for the treatment or services you’ve had after you’ve submitted a claim, it’s a claim denial. Sometimes your insurance company can inform you in advance that they won’t cover your costs for a particular medical service; it’s called pre-authorization denial.
Whatever the type of denial, you have the right to appeal and get the decision reversed, or at least get your insurance company to pay a part of the treatment or service.
What are the Reasons for Health Insurance Denials
There are several reasons why your health insurance company might be compelled to deny your claim. Some denials can be easily revered, while others aren’t so easy to address. Understanding their reasons can help you make an informed decision on how to go about with your claim.
1. Errors in Paperwork
The wrong name of your healthcare provider or any other error in the application is one of the most common reasons your health insurance denies your claim. Even small errors like billing codes can be the reason for claim denial.
2. Medical Service Claimed is Not a Necessity
Before your insurance company proceeds with payments for your claim, they need to ensure that the service you claimed is a medical necessity.
Consult with your healthcare provider to explain why you need the service to avoid a claim denial.
3. Alternative Services
Insurers may deem the service you claimed isn’t the only treatment for your medical necessity. Sometimes, there are cheaper alternatives to fix your condition.
If you try cheaper alternates first, you’re more likely to get your claim approved in the first application.
4. Your Plan Doesn’t Cover the Claimed Service
Services like cosmetic surgeries, dental treatments, and those not sanctioned by the FDA, are likely to be denied. It’s also important to check a particular state’s definition of the health benefits of the Affordable Care Act before you submit a claim.
Healthcare plans that aren’t regulated by the Affordable Care Act are likely to have significant gaps in their covered benefits, such as mental health care, maternity care, and prescription drugs.
5. Issues with Provider Network
Most health insurers have a limited network of healthcare providers and facilities, according to the plan. If you want to get the services outside of this network, your claim will likely be denied.
However, if a particular health provider outside of the network is the only facility providing services that you need, your insurer can agree to proceed with the claim. Keep in mind you have to convince your insurance company that no one else provides the services you need, not at least in the plan’s network.
Overturning claim denials can be challenging, so it’s far better to prepare your claim wisely. Even if your claim gets denied, you have plenty of options to get a decision in your favor.
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