A health insurance claims denial is the refusal of an insurance company to pay for a medical service, medication, or procedure that you believe should be covered by your policy. It’s important to understand that every insurance policy is different. Some cover more, and some cover less. Also, there are many reasons why a claim may be denied.
The insurer’s decision to deny payment may be based on many factors, ranging from pre-authorization requirements to insufficient medical necessity. The problem with healthcare is that it’s not just a financial transaction but also a personal one. And sometimes, these two aspects conflict, leading to a patient being left in the lurch when an insurer decides to deny their claim.
Health Insurance Claims Denial Reasons
There are many reasons why your health insurance claim may be denied, but some of the most common ones include the following:
- Pre-authorization requirements: Many healthcare providers will require patients to get pre-authorization from their insurer before receiving treatment. This may consist of tests, procedures, or surgeries. If someone doesn’t obtain pre-authorization before having surgery or going through with an expensive treatment plan, some insurers may deny the claim for reimbursement because it was not properly approved beforehand.
- Coverage limitations: This refers to services not covered by your plan. If there is no coverage for a certain procedure or test in your plan and you receive it anyway, your claim will be denied because it was an uncovered service.
- Medical necessity: Health insurance companies often deny claims for services they deem unnecessary or excessive. This includes medical care not within the guidelines of generally accepted practices in the medical community.
- Claim form errors: Claims can be denied because of mistakes made on the form by either you or your doctor. This could be anything from misspelled words on a medical report to incorrect dates (such as reporting an incident two days before when it occurred).
We Can Help!
Health insurance claims denial is a common problem. It can be frustrating to know that you’ve paid your health insurance premiums but still do not have coverage when needed. That is why it is crucial to find the right insurance coverage.
For assistance in finding the right insurance coverage that provides quality care, contact Health Insurance Duo today.