There are only a handful of reasons that may lead to a health care service not getting approved or a claim not being paid and they fall into one of these 5 reasons:
The claim has errors.
Minor data errors are the most common issue for claim denials. Sometimes, a provider may code the submission wrong, leaving information out, misspell your name or have your birthday wrong. Your Explanation of Benefits (EOB) will give you clues, so check it first. If you find an error, ask your provider to correct the information and submit your claim again.
You used a provider who isn't in your health plan's network.
Some plans only cover care if you use providers and facilities in your plan's network. If you go out of network, your plan may not cover any of the costs. Other plans may only cover some of the out-of-network costs, leaving you to pay the difference.
Your care needed approval ahead of time.
Some procedures, like CT scans, MRIs and certain surgeries usually require prior authorization. If a claim isn't covered because it wasn't authorized in advance, talk to the doctor who ordered it. He/she may be able to submit patient records that show you needed the service. If your doctor doesn't help, call your insurance provider. They can reach out to your doctor on your behalf.
You get care that isn't covered.
Your health plan may not provide that benefit. For example, your plan may not cover weight-loss surgery. In that case, it doesn't undergo medical review. If your plan doesn't cover it, the procedure won't be approved. This is called a coverage limit or contract exclusion.
The claim could also be denied for a medical reason. These types of denials may include:
*The services are not considered medically necessary.
*The right level of care wasn't provided given your condition.
*The treatment hasn't been proven effective or is considered experimental for your condition.
The claim went to the wrong insurance company.
If you have a second health plan, like one from your employer and one from your spouse's employer, the provider may have billed the wrong company. Or your provider may have outdated information if you changed insurers. When you get your EOB, check to see if it is from the right health plan, then contact your provider.
Sources: Reasons for Health Claim Denials and What You Should Do, VeryWellHealth, 2022; What to Do When Health Insurance Won't Pay,insurance.com, 2022; Appealing a Health Care Decision,healthcare.gov, 2022
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