Help for Denied Health Insurance Claims

In Health Insurance by Keith

Has your health insurance claim been denied?

Do you need help for denied health insurance claims? It’s very frustrating to get a denial from your health insurance provider. You may feel like you will be stuck paying for anything that is denied, but that probably isn’t the case. Most denials that I see are usually taken care of with just one or two phone calls. Here are a few things that may help you:

  1. Don’t panic. Most situations are easily fixed.
  2. Call your insurance company and ask them “Why” it was denied.
    1. In my experience, most are for improper coding.  In this case, the claim is sent back to the doctor or hospital for reprocessing and it will usually correct itself.
    2. No prior authorization.  If this is the case, you need to speak to the medical office that was supposed to get the authorization.  This is the usually the responsibility of the medical provider.  This means that if they did not get the prior authorization, they may end up writing off the cost and you would not be responsible for the denied claim.

  • It is always a good idea to call your insurance company before any surgery or procedure to make sure the authorization was approved.
  1. If it is for a prescription,
    1. Check with the insurance company and see if any prior authorization, step-therapy, or quantity limits apply.  This can be handled, if needed, through your physician’s office.
  2. Out of network.
    1. If you willfully or unintentionally went to an out-of-network provider, you will be responsible for the claim, unless…
      1. It was an emergency situation.  If that was the case, the insurance company will pay
      2. You can always appeal.
        1. If none of these situations apply to your denial.
        2. Ask for an appeal.

If non of these situations apply to your denial, you can always appeal.  With my clients, the first line of defense is, well, me. Call your agent, he or she should be able to direct you in the right direction and give you some guidance. If they can’t or won’t, get a new agent.