Medical Claims: The Top 5 Reasons for Insurance Plan Denials

In Sonoma County, you would probably prefer to sit back, sipping on a glass of wine, rather than worrying about insurance denials. Unfortunately, denials are all part of the health insurance game, and while denials may be irreversible, some rejections can be fixed and resolved relatively quick. The one definite after receiving a denial is that you, as the insured, are entitled to an explanation. However, while you await the detailed reason for your denial and get ready to appeal the decision, it does pay to familiarize yourself with the 5 main reasons for health insurance plan denials.
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1. Out of Network Provider

Many insurance plans fall under one of two headings: (1) a health maintenance organization or (2) an exclusive provider organization. If your plan falls into one of those categories, then you may have been denied because you may have gone to an out of network provider. While some providers may still offer certain benefits or coverage for out of network services, like emergent care, many do not, meaning the costs associated with the visit are your responsibility.
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2. Transcription Errors

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While denials are frustrating and may be irreversible, rejections that are the result of transcription errors may be resolved quickly. Transcription errors refer to minor mistakes when filling in forms, either on your part or the providers. Some examples of transcription mistakes are misspelled names, wrong birthday or any number of other typos.
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3. Wrong Billing Address

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Another fixable error is the use of a wrong billing address. Sometimes a doctor’s office does not send the paperwork to the right company. Other issues are if you forget to update your insurance information with the hospital or office. Make sure that your provider and practitioner have the same up to date information to avoid these types of errors.
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4. No Referral or Authorization

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Many insurers require prior authorization or precertification for certain procedures, like MRIs and CT scans. Therefore, if you follow through with the procedure without the appropriate authorization, then your claim may be denied. Sometimes, though, claims are mistakenly denied, so ask your doctor for assistance if this is the case.

5. Noncovered Charges

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There are stipulations and exclusions with almost every policy. Therefore, before going in for dental surgery or infertility treatments, check your policy and make sure you are covered. It is important when looking for a health insurance plan that you find one that will suit all your health needs. Sometimes, while it is nice to be self-sufficient, it is beneficial to ask for help when appealing a denial or trying to find the right insurance plan.
 
Don’t get lost in health insurance denials, find a Santa Rosa health insurance broker today. Sackett Insurance Services will help their clients solve issues with insurance denials. It’s one of the many benefits to having a health insurance broker. Don’t waste time, contact a Sackett Insurance broker by calling 707-823-3689 or connecting with them through Facebook or LinkedIn. Also, subscribe to the blog of Sackett and Associates to stay informed on all things health related.