A health insurance denial happens when your health insurance company refuses to pay for something.
Some reasons are simple and relatively easy to fix, while some are more difficult to address.
Public, but your insurer has you listed as John O.
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Or maybe the practitioner’s office submitted the claim with the wrongbilling code.
Questions about medical necessityThe insurer believes the requested service is notmedically necessary.
The service just isn’t covered by your planThe requested service isnt a covered benefit.
This is common for things like cosmetic surgery or treatments not approved by the FDA.
In that case, they mightmake an exception and provide coverage.
But balance billing is still allowed if you knowingly seek care from an out-of-connection provider.
Missing detailsPerhaps there was insufficient information provided with the claim or pre-authorization request.
But a denial doesnt mean youre notallowedto have that particular healthcare service.
Summary
There is a wide range of reasons for claim denials and prior authorization denials.
If your health plan denies a claim or a prior authorization request, don’t panic.
It’s possible that a simple clerical error caused the problem.
Your doctor or hospital will likely lead the way in the appeals process.
Pollitz, Karen, et al.
Kaiser Family Foundation.Consumer survey highlights problems with denied health insurance claims.
National Academy for State Health Policy.State definitions of medical necessity under the Medicaid EPSDT benefit.
Burns J.There’s a better way to do step therapy.Manag Care.
2018;27(11):1214.
Consumer Reports.Hazardous health plans - coverage gaps can leave you in big trouble.
Centers for Medicare and Medicaid Services.Advisory committee on ground ambulance and patient billing (GAPB).
Patient Advocate Foundation.What does an approved pre-authorization mean?
HealthCare.gov.How to appeal an insurance company decision.
U.S. Health and Human Services.Cancellations & appeals.
HealthCare,gov.External review.
