Reasons Behind Health Insurance Claims Denial

There are many reasons why your health insurance company may deny covering your claim. One of the most important things you need to do is to read through the Explanation of Benefits (EOB).

The Explanation of Benefits will tell you everything you need to know regarding you office visit, procedures or tests performed, and explanation codes. If you can’t find the answer, then call your insurance provider, so you save yourself time and money in the future.

There are several types of insurance networks, and each one has a different set of requirements you must meet. The different networks are listed below.

  • Exclusive Provider Organization (EPO)
  • Health Maintenance Organization (HMO)
  • Point of Service (POS)
  • Preferred Provider Organization (PPO)

Some plans cover a portion of an out of network doctor while others won’t cover any of it. Before you buy insurance, make sure you go to their website and see if your doctors are in their network.

health insurance plans

Sometimes the easiest thing to do is purchase a plan based on which one covers your doctors. Don’t forget to make sure your blood tests are done at a facility in your network as well. Doctors are not the only thing that can fall out of network.

For example, a person gets a treatment from Anesthesiologist that outside of the network, during the time of surgery. He made sure the surgery, the surgeon, and the facility, all were in the network, but he never realized the anesthesiologist was not a part of the medical facility and is paid separately.

He could not even think he would have been able to request a different anesthesiologist for the procedure since that was the medical facilities on staff one. If he knew, he would have looked into getting a different anesthesiologist for that surgery.

Special Procedures And Medication

If you are expecting to have a surgery performed or uncommon testing due to something that runs in your family or a recent medical diagnosis, make sure your insurance company covers those procedures.

Call your doctor and find out what tests and operations you may find yourself needing to have done and then check your EOB or call your insurance provider and see what the expected out of pocket cost will be and whether or not they will cover any of it.

Medication is a big one as well. If you have medications, you take regularly, then go to the provider’s drug coverage section and see if your prescription drugs are in there.

Some people can easily switch medication while other have limited options as to what works for them, make sure you take that into consideration when picking a plan.

Referrals And Pre-authorizations

Some insurance companies require a referral or pre-authorization to see specialists even if they are in your network; if you do not get that referral or pre-authorization, then the insurance company will not pay that bill.

Specialists are expensive, and many companies are now requiring your general practitioner to refer you to them. You will also need to make sure you get the correct one. One is getting permission from another doctor, and the other is permission from the insurance company.

Referrals are a recommendation to a specialist from a general practitioner while the other is asking the insurance company to approve a request to fill a certain medication or have a specialized surgery not covered in their EOB.

Explanation of benefits

If the procedure or medication is approved, the out of pocket or coinsurance amount will probably be higher than it would be for something that is approved in the EOB.

Transcription Errors

Small errors are a possible issue but corrected rather easily. For instance, billing the wrong insurance company, incorrect date of birth or a misspelled name or address.

Make sure your information is up to date and that there are no errors in your profile information when you visit your doctor. If you come across one of those issues, just update the information and have the doctor resubmit a claim. They want their money as much as you don’t want to pay the bill, so they will happily work with you to resolve the issue.


If you find yourself in a situation where you owe a large sum of money, because the insurance company won’t cover the claim, then try to negotiate a payment plan.

Many doctors and hospitals will work out a payment plan. They want their money even if it takes them two years to get paid in full.

If you are on a regular payment plan, they will continue to see you as long as you are diligent about making your payments on time and in the agreed amount.

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