Nothing is more stressful after you suffer from a major health problem than receiving notice that your health insurance will not cover the treatment you received. When you are trying to recover from a significant illness and injury, a denied claim can be disastrous. It is important to understand the various reasons why a health insurance claim may be denied, so you can take appropriate action when challenging the denial.
Clerical errors and missing information can lead to denials
One reason claims are denied is due to mistakes made in paperwork. For example, your physician may have submitted a claim under the wrong name, or there may be details about your treatment that are missing in your claim. Clarifying the clerical error can help in such situations.
Was the treatment medically necessary?
Another reason insurers may deny a claim is because they determined the treatment was not necessary. In this situation, it can help for you or your doctor to provide your insurer with further information regarding the necessity of your treatment.
What the treatment the least costly option?
Insurers are generally looking out for their bottom line. They want patients to attempt the least-costly option first, to see if that treatment is effective. This can lead to a denial. Again, having your physician provide your insurer about why you may have needed a more costly treatment may help.
Coverage and network issues
Some procedures may not be covered by your insurance, which could lead to a denial. In addition, your insurer generally has a network of physicians whose care they will be covered. If your treatment is not covered by your policy or was submitted by a physician who was not in network, your treatment may not be covered.
What to do following a denied claim
Your health insurance policy will have a procedure in place for appealing a denied claim. It is important to follow this process carefully and leave a paper trail. If the issue cannot be resolved internally, then it may be time for a government agency or attorney in Texas to review the denial and take appropriate action.