Real answers for your healthcare questions
Why did my health insurance deny my claim?
Answer
A claim can be denied for many reasons, including missing information, coding errors, lack of prior authorization, use of an out of network provider, a service the plan says is not covered, or a determination that the service did not meet the plan's medical necessity rules.
What to Know
A denial does not always mean you owe the full bill or that the decision is final. The Explanation of Benefits should identify the reason, and sometimes the provider can correct and resubmit the claim. Other denials may require a formal appeal.
What to Do Next
Read the denial reason before paying the bill. Compare the EOB with the provider's bill, contact the insurer or provider for clarification, and follow the plan's appeal deadline if you believe the claim should be covered.
Agent Perspectives
Be the first agent to share a perspective
Are you a licensed agent? Help clients with practical advice. Your name and profile appear with your answer.