When an insurance company refuses to pay a healthcare claim made by an insured, it is known as a denial of insurance. Your doctor (and you) must provide the insurance company with sufficient information documenting your medical problem and the treatment proposed or administered. Your insurer has the right to deny payment for such a test even if you really need it because you have not followed the health plan's rules. If you request prior authorization for a service to be performed by an out-of-network provider, the insurer may deny the authorization but be willing to consider it if you choose a different health care provider.
Cathryn Donaldson, a spokeswoman for America's Health Insurance Plans, says prior authorisation is not intended to hinder patient care. You haven't followed your health plan's rulesSay your health plan requires you to get prior authorisation for a certain non-emergency test. If you don't take action in time after a health insurance claim is denied, you could find yourself paying thousands of dollars in medical bills. Health insurers are working with doctors, hospitals, medical groups and other care providers to improve prior authorisation.
So if something has been denied because it's not a covered service, saying something is medically necessary doesn't count, Jolley says. Whether your health plan denies a claim for a service you've already received or denies a prior authorisation request, receiving a denial is frustrating. If you appeal a health claim twice, you can request an independent review or go to your state insurance department, depending on the insurer's policies. Provider network issuesDepending on how your plan's health care management system is structured, you may only be covered for services provided by providers and facilities that are part of your plan's provider network.
This explanation usually comes in a document called an Explanation of Benefits (EOB) from your insurer. For example, you have requested an MRI of your foot, but your healthcare provider's office has not sent any information about what is wrong with your foot. Please note that the provider may bill you for the difference between what your insurer pays and what the provider charges, as the provider has not signed a network agreement with your insurer.