5 Reasons a Claim May Be Denied

Believe it or not, there are only a handful of reasons that may lead to a health care service not getting approved or a claim not being paid.

They fall into these five buckets.

The claim has errors. Minor data errors are the most common culprit for claim denials. Sometimes, a provider may code the submission wrong, leave information out, misspell your name or have your birth date wrong. Your explanation of benefits (EOB) will give you clues, so check it first. If you find an error, ask your provider to correct the information and submit your claim again.

You used a provider who isn’t in your health plan’s network. Some plans only cover care if you use providers and facilities in your plan’s network. If you go out of network, your plan may not cover any of the costs. Other plans may only cover some of the out-of-network costs, and you have to pay the difference.

Your care needed approval ahead of time. Some procedures, like CT scans, MRIs and certain surgeries, usually require prior authorization. If a claim isn’t covered because it wasn’t authorized in advance, talk to the provider who ordered it. Your provider may be able to submit patient records that show you needed the service.

You get care that isn’t covered. Your health plan may not provide that benefit. For example, your plan may not cover weight-loss surgery. In that case, it doesn’t undergo medical review. If your plan doesn’t cover it, the procedure won’t be approved. This is called a coverage limit or contract exclusion.

If you lost health plan coverage, your claim may not be covered. This may happen if you don’t pay your monthly premiums or run out of COBRA.

The claim could also be denied for a medical reason. These types of denials may include:

• The services are not considered medically necessary.
• The right level of care wasn't provided given your condition.
• The treatment hasn’t been proven effective or is considered experimental for your condition.

The claim went to the wrong insurance company. If you have a second health plan, like one from your employer and one from your spouse’s employer, the provider may have billed the wrong company. Or your care provider may have outdated information if you changed insurers. When you get your EOB, check to see if it is from the right health plan, then contact your provider.

Sources: Reasons for Health Claim Denials and What You Should Do,  VeryWellHealth, 2023; What to Do When Health Insurance Won’t Pay,  Insurance.com, 2023; Appealing a Health Care Decision, HealthCare.gov 

Originally published 6/30/2020; Revised 2022, 2023