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Understanding why a medical claim is denied or rejected

On Behalf of | Aug 6, 2020 | Insurance Disputes

When residents in Oklahoma and elsewhere fall ill or suffer an injury, they likely rely on their health insurance to reduce or cover the costs of medical tests and treatments. However, when one receives notice that a claim for a medical procedure they had done was denied, this can create many emotions and concerns. First, as a policyholder, it was understood that the procedure was covered. Second, the funds to cover the costs of the procedure out-of-pocket are not available. Finally, one is unsure what to do when a health insurance claim is denied.

Steps to take when medical claim is denied

Policyholders should note that they are entitled to appeal any denial decisions. However, prior to invoking this right, it may be most beneficial to determine if any errors were made. Speaking directly with the health insurer could help establish whether a denial occurred because the claim was entered in wrong, there was missing information or the claims processing agent made a mistake.

Claim denial

If, after taking this step, the claim is still denied, the appeals process may be necessary. When a claim is denied, this means that the insurance company does not approve payment for the specific medical claim. For example, the insurer has made the decision to not pay for the listed procedure, test or prescription.

Claim rejected

This differs from a rejected claim. This occurs when the claim does not get processed due to incorrect information. Thus, the claim is rejected and an appeal is not necessary. What is necessary is to correct any errors made and resubmit the claim so the processing procedure can begin.

Appealing denied claims

The cause of a denial could be due to medical billing errors, the plan does not cover what is being claimed or is doe not consider the procedure to be medically necessary, the policyholder exceeded the coverage limits in their plan, the drug or therapy is not part of the policyholder’s plan or out-of-network services were used.

While it may not make sense to appeal a denial for a claim of services not covered in your plan, a claim for out-of-network services or when the coverage limit has been exceeded, there are good causes to appeal a denial. If a policyholder seeks to file an appeal, this is done through an appeal letter sent to one’s health insurance company.

Because this can be an emotional, complex and frustrating process, it is important that one fully understands their rights throughout this process. Seeking assistance could help ensure all the proper steps are taken and your rights are properly protected throughout the entire process.