List of Reasons Why Health Insurance Claims Are Denied

Health insurance claims can be fully or partially denied, for a variety of reasons. When a claim denial occurs, the patient and provider have the opportunity to appeal the decision. You can reduce the chance that a claim will be denied by being prepared before you receive or render services.たとえば、サービスの事前承認を得るための健康保険プランの手順に従ってください。また、レンダリングまたは受信しているサービスが医療の必要性基準ガイドラインに該当することを確認してください。 In addition, first confirm that benefits are covered, and if they are, determine and their limitations.

1. Lack of Medical Necessity

   • In order to pay claims for medical services, the care rendered must be medically necessary. Often, routine services are not questioned.ただし、医師のニュースWebサイトによると、健康保険プランは、医療提供者が患者が専門の医師の訪問、手術、および非ルーチンの手順を受け取るための医学的ニーズを示すことを要求する場合があります。多くの健康保険プランは、確立された基準に基づいて医学的必要性を基づいており、提出された請求が医学的に必要ではないとみなされる場合、プロバイダーが別の方法で証明できない限り、請求は拒否される可能性があります。

   Lack of Pre-authorization

   • A fundamental practice of managed care is pre-authorization of services.多くの健康保険プランは、入院、手順、手術、行動および薬物乱用のケアなど、非営利の医療サービスを綿密に管理しています。 These services often require the patient to obtain pre-authorization of services before receiving services. Failure to obtain pre-authorization often results in an administrative denial of claims payment. Providers often obtain the pre-authorization on behalf of the patient to prevent this from occurring.

   Benefits Exclusion or Exhaustion

   • Most health insurance companies have a list of services that are not covered. Health Net Federal Services Webサイトによると、美容整形手術、不妊治療、実験手術、胃バイパス、メタドン治療などのサービスは通常、福利厚生計画の範囲から除外されます。 In addition to exclusions, some benefits may have limitations. For example, your health insurance may cover only 30 days of inpatient treatment for behavioral problems or substance abuse. When a claim is submitted for benefits that either are excluded or have exceeded the benefit limitation, they will be denied.