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Reasons for Health Insurance Claim Denials | by heidi


A health insurance denial happens when your health insurance company refuses to pay for something. If this happens after you've had the medical service and a claim has been submitted, it's called a claim denial. Insurers also sometimes state ahead of time that they won't pay for a particular service, during the pre-authorization process; this is known as a pre-authorization—or prior authorization—denial. In both cases, you can appeal and may be able to get your insurer to reverse their decision and agree to pay for at least part of the service you need.

This article will explain how and why claim denials or pre-authorization denials happen, and what you can do if it happens to you.

man and woman looking confused at paperwork

Why Health Insurers Issue Denials

There are literally hundreds of reasons a health plan might deny payment for a healthcare service. Some reasons are simple and relatively easy to fix, while some are more difficult to address.

Common reasons for health insurance denials include:

Paperwork errors or mix-ups

For example, your healthcare provider’s office submitted a claim for John Q. Public, but your insurer has you listed as John O. Public. Or maybe the practitioner's office submitted the claim with the wrong billing code.

Questions about medical necessity

The insurer believes the requested service is not medically necessary. There are two possible reasons for this:1

You really don’t need the requested service.

You need the service, but you haven’t convinced your health insurer of that. Perhaps you and your healthcare provider need to provide more information about why you need the requested service.

Cost control

The insurer wants you to try a different, usually less expensive, option first. In this case, many times the requested service will be approved if you try the less expensive option first and it doesn’t work (step therapy for prescription drugs is a common example of this).2

The service just isn't covered by your plan

The requested service isn’t a covered benefit. This is common for things like cosmetic surgery or treatments not approved by the FDA. It's also common for services that don't fall within your state's definition of the Affordable Care Act's essential health benefits—if your plan is obtained in the individual or small group market—which can include things like acupuncture or chiropractic services. (Note that if you have an employer-sponsored plan that's self-insured or obtained in the large group market, the ACA's essential health benefits are not required to be covered; check your plan details to be sure you understand what is and isn't covered by your policy).

Significant gaps in covered benefits are also common if you've purchased a plan that isn't regulated by Affordable Care Act rules (such as a short-term health plan or fixed indemnity plan) and thus doesn't have to cover services that you might otherwise expect a health plan to cover—things like prescription drugs, mental health care, maternity care, etc.3

Provider network issues

Depending on how your health plan's managed care system is structured, you may only have coverage for services provided by healthcare providers and facilities that are part of your plan's provider network.4 If you go outside the provider network, you can thus expect your insurer to deny the claim.

If you're seeking prior authorization for a service to be performed by an out-of-network provider, the insurer might be willing to consider it if you choose a different healthcare provider who is within your plan's network. Alternately, you might try to convince the insurance company that your chosen provider is the only provider capable of providing this service. In that case, they can make an exception and provide coverage.

Be aware that the provider may balance bill you for the difference between what your insurer pays and what the provider charges, since this provider hasn't signed a network agreement with your insurer.5 The No Surprises Act took effect in January 2022, prohibiting surprise balance billing, which refers to emergency situations or care provided by an out-of-network medical provider at an in-network facility. But balance billing is still allowed if you knowingly seek care from an out-of-network provider.

Missing details

Perhaps there was insufficient information provided with the claim or pre-authorization request. For example, you’ve requested an MRI of your foot, but your healthcare provider’s office didn’t send any information about what was wrong with your foot.

You didn't follow your health plan's rules

Let’s say your health plan requires you to get pre-authorization for a particular non-emergency test. You have the test done without getting pre-authorization from your insurer. Your insurer has the right to deny payment for that test—even if you really needed it—because you didn’t follow the health plan’s rules.6

In any non-emergency situation, your best bet is to contact your insurer before scheduling a medical procedure, to make sure you follow any rules they have regarding provider networks, prior authorization, step therapy, etc.

What to Do About a Denial

Whether your health plan denies a claim for a service you’ve already received or it denies a pre-authorization request, getting a denial is frustrating. But a denial doesn’t mean you’re not allowed to have that particular healthcare service. Instead, it either means that your insurer won’t pay for the service, or that you need to appeal the decision and potentially have it covered if your appeal is successful.7

If you’re willing to pay for the treatment yourself, out-of-pocket, you’ll probably be able to have the healthcare service without further delay.

If you can’t afford to pay out-of-pocket, or if you’d rather not, you may want to look into the cause of the denial to see if you can get it overturned. This process is called appealing a denial, and it can be done in response to a prior authorization denial or the denial of a post-service claim.

All non-grandfathered health plans have a process in place for appealing denials, which was codified by the Affordable Care Act8 (grandfathered plans will generally have their own appeals process, but they don't have to comply with the ACA's specific requirements for an internal and external appeals process). The appeals process will be outlined in the information you receive when you’re notified that your claim or pre-authorization request has been denied.

Follow your health plan’s appeals process carefully. Keep good records of each step you’ve taken, when you took it, and who you spoke with if you’re doing things on the telephone. In most cases, your healthcare provider's office will be closely involved in the appeals process too, and will handle a good chunk of the necessary documentation that has to be sent to the insurer.

If you’re not able to resolve the issue by working internally within your health plan, you may request an external review of the denial. This means a government agency or other neutral third party will review your claim denial9 (there is no guaranteed access to an external review if your health plan is grandfathered, but the plan may still offer this voluntarily).