The Most Common Denials:
Policy Limitations

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The health plan makes its denial decisions based on policies identified in the policy booklet you receive. This policy booklet lists those procedures and services that the health plan will cover or exclude for payment, as well as, identifying items that must be pre-authorized before payment is made. If a medical service or procedure is denied, then the health plan should forward to you and the physician a denial in writing, explaining the details of why the procedure or service was denied.

Here is a list of the most common policy coverage denials

  1. The medical service/treatment was not authorized.  Today, Health Plans are trying to reduce the amount they pay on claims.  One method of this cost containment practice is by having the patient or medical provider pre-authorize medical treatment.  By doing this, the health plan can determine if the medical procedure is both medically necessary and cost beneficial.

  2. A very common, but frustrating policy denial are those related to timeliness.  Health plans limit the amount of time the initial claim must be filed with them, many of which use the 90 day initial submission timeframe.  Health plans also place limits on the amount of time the appeal of a denial must submitted to the health plan, which may range anywhere between 95 days to 120 days from the date of the denial.  If the initial claim or appeal of a claim denial are not submitted within these time frames, the health plan will deny the claim and no longer consider any appeals.

  3. Another denial related to policy coverage includes a denial because the medical service/treatment was not a covered benefit under the plan.  If you receive this denial, you must confirm this decision by reviewing your policy booklet for confirmation.

  4. Other denials include benefit maximum has been met, duplicate claim denials or denials due to possible pre-existing.

How do you combat a non-covered denial?  The following steps may help.

  1. Review the denial with your policy booklet and verify that their denial is justified. If their reason for denial is unclear, call the customer service unit at the health plan for a more descriptive explanation. Record your conversation and document the name of the individual you spoke with for future reference.

  2. Did you abide by the policy and limitations by the plan?

  3. Did your medical provider do the appropriate authorization requests to confirm that the medical service would be covered?

  4. Non-covered denials can be appealed based on medical necessity