A health insurance claim denial happens when your health insurance provider refuses to pay for something. Health insurance denial is enough to make you feel sick again especially if you are stuck with huge medical bills as a result.
Fortunately, you are entitled to a detailed explanation from your insurer in the form of EOBs (explanation of benefits). Note that EOBs are always full of abbreviations and codes, intended to explain what will be paid, and why part or the entire health insurance claim is denied. Though most insurance companies offer a key to help you understand these codes and abbreviations, that doesn’t answer your questions.
Here are the reasons health insurance companies deny medical claims.
1. Incorrect patient identification details
It’s important to provide accurate identification details when filing a medical claim. Without this, your health insurance service provider can’t figure out the patient to whom they should make payment. Simple mistakes such as misspelled patient name and providing an incorrect date of birth can deny you your health insurance claim.
Did you misspell your name? Does your medical claim paperwork indicate that you were born in 1968 instead of 1986? Always be careful when filling in your medical claim paperwork. It’s also advisable to seek help from a relevant attorney.
2. Your charges aren’t covered
It’s possible that your policy didn’t cover the procedure you had even if you think it should have been. Check the terms and conditions of your health insurance policy. Some policies don’t cover specific categories of healthcare such as dental surgery and infertility treatments. If you think you may require healthcare cover that’s excluded from your current policy, it’s time to shop for a new health insurance policy.
3. Pre-authorization or referral was needed
Medical procedures such as MRISs or CT scans often require pre-authorization which a medical practitioner should request on behalf of the patient. Sometimes, your doctor might turn you away if you don’t have pre-authorization. In case your medical claim was denied, but your healthcare provider had ordered the tests, it’s important to ask the doctor to contact the policy provider on your behalf.
4. You opted for an out-of-network health care provider
If your health insurance service provider is an exclusive provider organization or a health maintenance organization, perhaps your claim was denied because you used healthcare services outside the company’s network for care. That means you were treated by a doctor whose organization hasn’t agreed to the terms and conditions set by your health insurance company.
In case you received nonemergency or elective care and didn’t have out-of-network benefits, your healthcare plan might deny the claim. That makes all the required payments your responsibility or the insurance company may require you to pay a larger share of the entire cost.
Lastly, if your medical claim was sent to the wrong health insurance company, it will be rejected. It’s advisable to check with your healthcare provider and be sure that every medical claim is sent to the right insurance company.