A health insurance claim is a request submitted to your health insurance provider – typically by your health care provider but sometimes by you – that seeks reimbursement for the cost of the care received.

For example, if you go to your family doctor for an annual check-up that involves a blood test and hearing exam, your doctor’s office will submit a list of costs to your insurance company for each service that was provided. Your insurance provider will then determine what percentage of the costs you will be responsible for based on the co-pay, deductible, out of pocket maximum, and coverage of your plan. They will then pay the rest of the claim bill.

A health insurance claim denial is when your health insurer declares they are not responsible for paying / reimbursing for the care that has already been provided. The responsibility to pay the medical bill is then shifted back to you.

Sometimes, certain health services require your health insurance provider to approve or deny responsibility before the healthcare service has been provided. This is called a pre-authorization or prior authorization. You are able to fight a pre-authorization denial as well as a regular denial.

There are a variety of reasons, but ultimately with a medical claim denial, the health insurer is stating that the service an individual received does not fall under the health insurance plan. Here are a few reasons why a health insurance provider would determine they are not responsible for paying the claim:

• Prior Authorization Was Required: At times, a claim may be denied because prior authorization from the insurance provider was required but the request was not submitted before the service was received.
• Missing or Incorrect Information: Mistakes happen! But when there are errors in a claim form—such as a misspelled name or missing piece of paperwork—a denial is likely. That is why it is important to double and even triple check information on your claim form and make sure that is it is filled out completely if you are the one submitting it.
• Outdated Insurance Information: Claims can be denied due to outdated insurance information, such as sending the claim to the wrong insurance company.
• Claim Was Filed Too Late: Most insurance companies have a window of time (6 months to 1 year) where they will accept claims. If you wait too long and miss the window, your claim is likely to be denied.
• Services Not Covered: There can be exclusions to your plan and some procedures may not be covered by your policy, or there may be a limitation to the number of visits for a particular service.

While the process of fighting a medical claim denial varies from state to state, here are the basic steps you may follow:

• Find out why the claim was denied. (You should receive an explanation in the mail, or may call your insurance provider to discover the reason.)
• Go over your plan policy (Once you have an explanation for the denial, you may want to check it against the terms of your health insurance plan to make sure the terms were not violated.)
• File an internal appeal (If you believe your claim has been wrongfully denied, you can ask to file an internal appeal with your health insurance provider. This process differs from company to company.)
• File an external appeal (If you have been unsuccessful with an internal appeal, you can take your appeal to a third-party reviewer. Many states offer external reviews, as does the federal government’s Department of Health and Human Services)

Fighting an insurance claim denial can be a time-consuming and exhausting process, especially if you are handling it alone. That’s why using aJust’s services can take the burden off your shoulders while also setting you up for success.