You need pre-authorization or a referral
Did you need to undergo a medical procedure such as an MRI or a CT scan? If so, your insurance provider may require a referral or pre-authorization from your physician.
Even if the facility agrees to provide the procedure without a referral or pre-authorization, your insurance provider may not agree to cover the cost. To rectify the situation, see if your doctor can reach out to your insurance carrier and let them know about ordering the procedure for you. (Physicians and other healthcare specialists using services like Fortis Medical Billing may have an easier time working with your insurance carrier.)
Your policy does not cover the procedure
Even with proper pre-authorization or a referral, you must check with your insurance provider or look over your policy to ensure your plan includes the procedure. Even if your carrier previously covered the procedure, your latest plan may not include it.
You used an out-of-network provider
Something else to double-check on your insurance plan is whether the provider you want to see is in your current provider network.
Provider networks are common for exclusive provider organizations and health maintenance organizations. If you do not use an approved provider who agrees to your carrier's payment terms, your insurance carrier may deny your claim. Occasionally, insurance companies will accept a claim from an out-of-network provider, but you may have to pay a higher percentage of the costs than you normally would.
If you want to have the option of using out-of-network providers, ask your current carrier if you can include out-of-network benefits on your current health insurance plan. That way, you receive non-emergency and/or elective treatment.
Your claim contains typos
A clerical error on your part may be the reason for your denial. Check to see whether you listed your birth date, name, address, and all other personal information correctly on your claim. If you notice a typo, reach out to your provider's customer service department to correct it.
Your physician billed the wrong provider
Perhaps the mistake was your doctor's and the wrong insurance carrier received your claim. This sometimes happens if you go to a doctor or another healthcare provider you have not been to in a while. They may have outdated or inaccurate policy information on file.
Do you have multiple health insurance policies? Maybe you and your spouse have separate plans through your employers but see the same physician. If so, your doctor may have sent the bill to your spouse's carrier rather than yours.
If your physician billed the wrong provider, see that the office sends the bill to the right company as soon as possible. Waiting too long could result in a denial because the bill did not arrive on time to qualify for approval.
Your service was not considered medically necessary
Another reason insurance companies deny claims is that they do not feel the requested service qualifies as medically necessary. Even though you may need a procedure, treatment, or service, you may have to make your policy provider understand why you need it.
Team up with your doctor to supply your carrier with adequate evidence of your medical need. Also, ask yourself if you truly need the service to improve your health or if you only want the service for vanity or nonessential reasons.
You did not choose the less-expensive option
Insurance companies are a business, which means they want more money coming in than they do funneling out. If you opt for a more expensive medical option when a less expensive one achieves the desired result, your carrier may deny your claim based on cost-efficiency.
Always choose the less-expensive procedure or treatment first. If results do not work the way your physician would like, then you can see if your provider would cover the more expensive option.
Do not lose hope if your carrier denies your claim. A phone call and the right information could change everything for the better.
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