Legal Guide

Health Insurance Denial

People buy health insurance to get benefits regarding health issues with idea that this will give peace and comfort. It will be surprising for you if the insurance company tells you that your health insurance policy will not cover your medical expenses like medication or treatment. The situation can be serious when you are unable to pay the doctor to get a prescription or to buy medicines and even the cost of hospitalization. You can challenge this denial in court to get results in your favor. 

Reasons for insurance denial

 There can be reasons for insurance claim denial. Some of the reasons are easy to fix while others can be complicated to be fixed. Following are some common reasons for insurance claim denial.

  • Duplicate claims

When people get insurance denial from insurance companies, they usually think that something went wrong with medical conditions or policies. But this is not the case in the majority of denial. One of the major reasons for denial is administrative issues by the provider. Usually, this blunder is done by the front desk secretary. He may have resubmitted the claim before the response of the insurance company. You can reduce the claim denial due to submitting duplicate claims by considering the following points.

  • Establishing an efficient and well-established process for submitting insurance claims.
  • Establishing a management solution with claim tracking and reporting.
  1. 2.  Issues with ICD 10 or wrong coding

Although new language coding is available to catalog the treatment chances of error still exist. Now modern software is available for automatic billing but coding issues still exist. Embedded coding in this software has made the billing process more efficient. Now more claims can be processed in a short time.

  1. Patient information missing or incorrect

Claim denial can be due to incorrect or even missing information on the claim. Front desk secretaries commit manual errors. These errors can be like the following.

  • Missing date of birth
  • Incorrect patient subscriber number
  • Insurance ineligibility
  1. Lack of Documentary support 

Insurance claims require much supportive documentation. In the absence of an organized and responsible front desk staff, some important documents needed for claim approval may be missing. 

Factors held responsible for specific insurance claims are very difficult to avoid. But can be avoided with trained and experienced staff equipped with the latest computer software. 

  1. 5. Missing premium installment

Although the majority of the time people pay premiums regularly but sometimes forget to pay an installment on time. To solve this issue, keep the record of premium installments and note the due date of payment. 

  1. Death by suicide

It is very important to know that insurance companies don’t pay for death due to suicide

 How to handle insurance denial?

You can solve the problems of insurance denial by following strategies.

  1. Review of claim notifications

It can be a good strategy to review all notifications regarding claims like remittance advice, or explanation of benefit, etc., from the insurance company. These notices can give information like claim full or partially pay, delayed, or even denied. Try to review notices like “unclean’ or contested. In response to this type of notices, resubmit the claim along with missing/correct documents.  

If the notification is clear then you have to send only correct information. On the other hand, if notification is not clear then it is better to call the insurance company to completely understand denial reasons. 

  1. 2. Don’t be demotivated be consistent

If your resubmitted claim is again denied and you think that decision is improper then no need to be demotivated. You have the option to go for an appeal against this decision. Before appealing, get all the needed information. Appeal procedures can be different in different states. Don’t forget to include an explanation of your reconsideration in the appeal. This reconsideration also requires the submission of some supportive documents.

  1. Don’t waste time

To get going smoothly, complete every task timely. Submit or resubmit claims on time and as early as possible. Obey the time specified by the state and company. Otherwise, there is the possibility to get the same denial again. 

  1. Get knowledge of the appeal process

Filing an appeal against a reclaim means that the insurance company is being asked to reconsider its decision. To get a better result, it will be good to get complete information about insurance company policies. Company’s actions can be dealt with effective manner if you know about company policies, and employer’s policies along with the policies of your state regarding appeal against a claim denial. 

There are three levels of appeal for denial claims.

  • Level one appeal

Following tasks are done at the first level.

  1. You and your doctor inform the insurance company about your bare reconsidering denial
  2. Your doctor contact the medical reviewer of the insurance plan for a complete understanding

This level of appeal is requested to prove that your claim fulfill the insurance guideline but is rejected incorrectly.

  • Level 2 appeal

At this level, the Medical Director of the insurance company who was not involved in previous decisions reviews the appeal. The main objective of this level of appeal is to convince that claim should be accepted within the coverage guideline of the company. 

  • Independent external review

At this level, an external review is carried out. The appeal is assessed by an independent reviewer from the insurance company and another doctor of the equal specialty of your existing doctor to approve or deny coverage. This is done when the internal review is either unsuccessful or not possible. 

  1. 5. Maintain a Record of disputed claims

Keep all records provided by the insurance company which you gathered during the call/visit with the company. It is also recommended to note down the full name of the representatives with whom you talked. Also, note down other denial reasons of claim like claim was partially paid or delayed. These records can be helpful when you go for the appeal to a higher level.

  1. Work together

Have a meeting with your doctor and his staff to get their help and support. Pay special attention to the person who will write the letter and submit its insurance company. Gets a supportive letter from the doctor containing medical reasons to get services to approve and notes about your response to the medicine which he prescribed. Get the result of any lab test conduct to diagnose your illness or injury. 

Don’t feel that you are alone. Many states have offered consumer assistance programs to help you regarding an appeal against a claim denial. You can get the contact information for these programs by contacting the state insurance plan department. This information can also be obtained from your insurance company. Help from the human resource department of your company can also be useful. 

State healthcare ombudsmen are also available. You can work along with them and get their support on claim issues. 

When someone purchases an insurance plan from an insurance company to get medical support timely, he fulfills all the requirements of the insurance company and pays premiums regularly with the expectation that everything will be in his favor at the time when help from the insurance company is needed. In the same way insurance company is also legally bound to facilitate the consumer by providing coverage plans according to commitments. This looks very simple but not. People or companies after paying expensive premiums are unable to get the proper coverage for which they are entitled. 

To cope with the claim denial, help from the insurance denial attorney or denial lawyer firm can be helpful. Because denial claims are challenged and appalled legally. It is difficult to understand the legal process of denial claims and to understand the policies of the insurance company. Only an experienced lawyer especially an expert to challenge denial claims should be hired. 


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