Why Was My Health Insurance Claim Denied? Part One: Prior Authorization

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medical-advocacy_72584497Health insurance helps to cover healthcare costs, but problems are common when you need to have services covered. When you have your health insurance claim denied, the out-of-pocket expenses can be detrimental.

Many procedures require a pre-authorization from your doctor. This tells your health insurer that the service is deemed medically necessary by your provider. However, even though you receive pre-authorization from your doctor, this does not necessarily mean that your health insurance company will pay 100% of the cost. Prior authorization might also be needed before a health insurer will cover the cost of certain prescription medications.

Health insurance companies require prior authorization for many reasons, especially to avoid medically unnecessary services and procedures. It’s not unusual though, for a provider to not contact the insurer for prior authorization, which could result in a claim denial. Additionally, it’s possible for the insurer to deny a claim even when they have received prior authorization for numerous reasons. Always talk to the health insurance carrier before any service or procedure that might require pre-authorization and stay proactive in your communication with your provider to ensure that they have taken steps to follow through with prior authorization.

What You Can Do

If you feel that you have been incorrectly denied, be sure to appeal the denial. Under the Affordable Care Act, your insurer must reach a decision about your appeal within a specified time frame. If you have already received the healthcare service, they have 60 days to reach a decision. If you have yet to receive the treatment, they have 30 days to reach a decision. They must reach a decision within 72 hours if you are appealing a claim for an urgent care facility.

To help protect yourself from health insurance claim denials, make sure you read and understand your individual policy. Make sure that you go over your renewed policy as well to double-check for any possible changes to your policy that you might have missed. You will receive a Summary of Benefits and Coverage from your health insurance company. If there is any part of your coverage that you are unsure of or does not make sense to you, contact your insurer so that they can clarify any questions you might have.




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