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Common reasons for health insurance claim denials

On Behalf of | May 26, 2021 | Delayed And Denied Insurance Claims | 0 comments

Many people in Austin have faced health challenges over the past year and a half, leading to costly medical bills. While they may be grateful that they have health insurance to cover these expenses, the fact is that sometimes a health insurance claim is denied. The following are some common reasons why health insurers deny policyholder’s claims.

Paperwork typos or incomplete claims

Sometimes your doctor’s office makes an error or typo on the claim, leading to a denial. For example, they may spell your name wrong, use the wrong billing code. In addition, your doctor’s office may have left necessary details out of the claim, for example, stating a procedure is needed but not explaining why.

Denials based on medical necessity

Sometimes your health insurer will deny a claim because they believe the service requested in the claim is not medically necessary. This can be very frustrating if you and your physician agree that you need the service denied. Sometimes your doctor can resolve this by providing the insurer with further information as to why the service is necessary.

Denials based on cost or coverage

Health insurers are, when it comes down to it, businesses and are looking out for their bottom line. They may deny your claim because they want you to try a less costly option first. They may also deny your claim by stating the requested service is not covered under your policy. Health insurers may also try to deny a claim by stating the treating physician was out-of-network.

Learn more about health insurance denials

Having your claim for benefits denied can be very distressing, especially if you are seriously ill or injured and are facing extensive medical bills. This post is for educational purposes only and does not contain legal advice. Our firm’s webpage on denied claims may be a useful resource for those wishing to learn more about this topic.