When Your Insurance Denies A Claim?

Even professionals who take care to prevent insurance payment pitfalls suffer denials. The process of handling refused insurance claims can sometimes be irritating, time-consuming, and complex.


Simple ways for overcoming claim denials can save time and money. Here are some fundamental guidelines for addressing claim denials.

1. Review All Claim Notifications Carefully.


It may seem apparent, but it is vital in the claims handling procedure. Examine any remittance advice, benefit explanation, or other notice from an insurance carrier regarding a claim.


It should state whether the claim was fully paid, partially paid, or denied. If the claim is deemed “unclean” or challenged, resubmit it with any missing or updated information. (“Insurance Claims 101: Avoiding Common Payment Pitfalls”) If the claim is partially paid or denied, the notification should state the reasons and detail the steps to resubmit the claim or file an appeal.


If the notification is unclear, contact the carrier. Aside from the stated reason for denial, you may discover that the claim was assessed wrongly due to a payer administrative error. You may also find that your filing procedures do not meet the company’s requirements but that modest changes will simplify future claims submissions.


2. Persistence

If your resubmitted claim is refused, you may appeal the decision using the carrier’s standards. Make sure you know what information to include in your appeal. Keep in mind that insurance companies and state laws may differ.

Your appeal should explain your reconsideration request and include any supporting documentation, such as a copy of the disputed claim and copies of previous correspondence with the company. If your claim is denied due to “medical necessity,” you may need to provide further evidence. Remember that the Health Insurance Portability and Accountability Act (HIPAA) requires you to secure psychotherapy notes and release only “minimum necessary” information.

Never give up. Resubmitting a claim or appealing a company’s decision may take several attempts. Persistence can show the insurance provider that you are serious about getting compensated.


3. Act Now

It’s critical to submit and resubmit claims within the timeframes set by the firm or state laws. Any requests for reconsideration or appeal may be dismissed as untimely if you do not supply the requested information.


4. Find Out How It Works.

Know the company’s appeals process before submitting an appeal. Knowing your carrier’s policies helps you respond to their behavior. Keep up with each carrier’s claims adjudication and appeal processes. Carriers generally post this information on their websites and, if requested, supply physical copies when you sign a new contract.


5. Keep Track Of Contested Claims.

When calling an insurance company for information regarding a claim, maintain a record of the information you receive, including the representative’s full name. Keep track of why the claim was partially paid, delayed, or refused your office’s steps to follow up on the claim and the conclusion.

These data can help you if you decide to appeal, file a complaint with the state insurance commissioner, or file a lawsuit. The data can also help your office avoid or resolve future claim denials by providing sample appeals letters and paperwork.


6. Help Is Available, Remember.

While dealing with claim denials might be irritating, it can save you time and money by alerting you to the insurance carriers’ expectations and criteria. By following the company’s billing procedures, you may be able to reduce future rejections and denials.


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