Having an insurance company deny a claim is frustrating and often confusing. The first thing to do when you receive a denial from your health insurance company is to read the explanation of benefits your insurance company has provided. It might take a few minutes, but hopefully you can determine the reason for the denial. In some cases, it may be that your insurance company has simply made a mistake. It could have been a keying error or any number of other errors might have happened.
Once you know why the claim has been denied, look carefully at the claim denial and make sure that the provider (doctor, hospital, etc..) name is correct on the EOB (explanation of benefits). You also want to make sure that the correct date of service appears on the claim as well as the correct procedure and diagnosis code if possible. If this information is not clear on the EOB, then I recommend calling the customer service department of your insurance company.
Ask them to explain the details of what was submitted on the claim and the reason for denial. Once you have the fact of the denial, you must then contact your provider of service (The doctor, hospital, or clinic where you were treated). Let them know that you have received a copy of the claim denial in the mail and ask them to review the claim. Often, if it was not a simple error on the part of the insurance company, it could be an error on the side of the provider. One of the most common denials I saw as a claims adjuster was “no authorization obtained”.
If your doctor’s office failed to obtain a precent prior to performing a service, then you will need to appeal the claim. In some cases your provider’s office will file the appeal on your behalf by resubmitting the claim to the insurance company’s appeals department along with a copy of your medical records, and explanation for why the procedure was medically necessary, and a request for an authorization to be given. In most cases, if you or the provider can prove medical necessity, then the insurance company will overturn the original decision and reprocess the claim.
If there is a question regarding your eligibility, then you will need to contact your employer or your insurance agent to find out why your eligibility has ended (assuming that you are not already aware of a lapse in coverage). If the eligibility problem is not resolved, then you will likely have no choice but to pay the provider for the services that were denied.
There are hundreds of reasons why claims are denied, but most problems can be resolved with a little research and a few phone calls to request that the claim be resubmitted by the provider for reconsideration by the insurance company.
In some cases, the insurance company might decide that a particular service that is being requested does not meet their criteria for medical necessity. If this is the case, then you will need to speak with your physician or provider of service to make certain that all facts pertaining to your condition have been properly submitted to the insurance company. If your provider does not agree with the denial and appeals the decision of the insurance company, and the service is still denied, then you should consider contacting your local Insurance Commissioner’s office. In some extreme cases, the Commissioner’s office can act as an intermediary to help resolve the issue.
In a very few cases, it is entirely possible that the insurance company simply isn’t playing by the rules. In other words, they are denying claims that should have otherwise been paid. If you have exhausted all options for appeal and your claim or medical procedure authorization is still denied, then you should contact an attorney.
It has been my experience over the years that most claims denials are nothing more than a keying error on the part of one party or another. Once the typo or keying error is corrected, the claims are reprocessed and the matter is resolved.