REASONS FOR CLAIMS DENIALS
There are numerous reasons why insurance companies may deny services or claims. It is important to review the reason your claim is denied, as it helps you determine your next steps.
Here are some of the most common scenarios for service or claim denials you may encounter:
Services are not covered by your health plan
Some insurance companies will not cover specific services, health care providers or types of treatment. This is known as benefit exclusion. The most common exclusion obstacle you will face as a patient with pulmonary hypertension (PH) is that your drug is not on your plan’s formulary, the limited list of drugs subject to coverage under the plan.
You will want to call your insurance company to verify the services it shows you have received and/or the coverage exclusions of your plan. Review this information with your provider to ensure the service was filed correctly and determine your next steps for appeal.
You can file an appeal if you receive a claim stating that the service is not a covered benefit or if you receive a denial for a prior authorization request. Learn how to file an appeal.
Medical necessity was not established
Prior authorization or a claim may be denied if the insurance company does not feel that the service you are requesting or received is appropriate for your condition and/or diagnosis. Many health plans require you to try several treatment options prior to covering more costly alternatives.
You can submit an appeal if your claim is denied. Work with your provider to collect all previous medical history and chart notes to support the reason for the prescribed service. Documented proof of medical history will support any information you provide in a letter to the insurance company.
Try also contacting the manufacturer of the product you are being prescribed, as it can often provide you with a copy of the package insert and results from the clinical trials. This information can help demonstrate efficacy and possibly cost effectiveness compared to other treatments.
Prior authorization was not obtained
Insurance companies may require individuals to get prior authorization before receiving a medical service. If this is not completed, you may receive an Explanation of Benefits (EOB) that states that the service/claim was denied because prior authorization was not obtained.
Some insurance companies will allow physicians to request a retroactive authorization. This will allow the insurance company to authorize treatment back to the time when your service was rendered. Be sure that you or your provider then requests that the denied claim be reprocessed referencing the authorization for correct payment. Learn how to obtain prior authorization.
If you have obtained prior authorization for a service and the claim is denied, provide copies of the authorization letters to your insurance company to show that proper procedures were followed.
Claim was filed incorrectly
Many insurance claim denials occur due to filing and/or processing errors. Many times this is not easily recognized because the denial reason on your Explanation of Benefits (EOB) did not specify that there was any filing or processing error.
You and your health care team will need to work very closely with the insurance company to ensure that the services it shows you received align with what you and/or your physician billed. Also, be sure to have the insurance company check the diagnosis code, as this could also affect what services are or are not covered.