No! You expected your health insurance to cover a service, and then you get the dreaded letter that it’s been denied. Why do claims get denied and when does it actually matter (that’s right, sometimes it doesn’t matter)?
Your health plan might refuse to pay for a service or treatment you received for many reasons. It’s good to know whether it was denied because of the services themselves OR because of how your provider submitted it. Why is this important? Because in the first case, you’ll probably be responsible for paying the claim. In the second, you won’t be.
Here are some common reasons claims get denied where you could be responsible:
- You didn’t get a referral or prior authorization when it was required
- The service isn’t covered by your plan
- You already used up your benefits for the service (like a cap on the number of physical therapy visits per year)
- You went out of network when you have an HMO
- Your insurance wasn’t effective at the time of the service
Don’t confuse these situations with those where a claim (or a portion of a claim) was denied because of how your provider submitted it to your insurance. This happens surprisingly frequently. It might be that:
- Your doctor didn’t submit the right billing code to your insurance plan
- Your doctor didn’t submit the claim in the timeframe your insurance required
- The service was actually covered as part of another claim or set of services
- The claim is a duplicate that was already paid
You might see these things show up on your EoBs, or Explanation of Benefits–the statements you get from your health plan just informing you about your coverage (the ones that say “This is Not a Bill”). Just know that if your provider made a mistake submitting a claim, or your insurer found that it had already been paid for, you’re not responsible!
So before you panic, look into the reason for the denial. And if you believe you were billed unfairly for the cost, you can always appeal the decision. All health plans have to honor a process of reviewing claim appeals from their members.