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Five Reasons a Health Insurance Claim May Not be Approved

We’ve all done it before: sat in a doctor’s office and filled out a lengthy form with our insurance information. The reason for all that information is to ensure your doctor can properly file a claim with the health insurer so you get all of the coverage you’re entitled to under your plan.

A claim is simply a bill that doctors and other health care providers send to a health insurer, such as Blue Cross and Blue Shield of Illinois (BCBSIL), for reimbursement after they have treated you. It is then BCBSIL or your insurer’s responsibility to review and process the claim appropriately and consistent with your benefits.

In most cases, your provider’s office will submit your claim so you don’t have to worry about it. But there are some instances when you may have to file the claim yourself, such as when you receive care from a provider who is not in the insurer’s network of contracted providers.

Once your claim has been processed by your insurance company, you’ll receive an Explanation of Benefits (EOB) statement that shows: 1) the amount billed by your provider to the insurance company, 2) how much your plan pays, and 3) the amount you may still owe to your provider (often called co-insurance).

There are a handful of reasons why a claim may not be approved for payment right away, and your EOB shows how you can file an appeal to have it reviewed again. Insurers must tell you the reason why a claim was not approved for payment or coverage. Here are a few reasons that you might see:

The claim has errors. Minor data errors are the most common culprit for claim denials. Sometimes, a provider may inadvertently code the submission incorrectly, accidentally leave information out, misspell your name, or have numbers in your birthdate inverted. Your EOB will give you clues, so check there first. If you find an error, ask your provider to correct the information and submit your claim again.

You used a provider that 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 may require prior authorization from the insurer. If a claim is denied because it required authorization in advance, talk to the doctor who ordered it. He or she may be able to submit patient records to show that the service was medically necessary. If your doctor is unable to help, your insurer can reach out to the provider on your behalf.

You get care that isn’t covered. Your health plan may not provide a benefit for certain procedures. For example, if your plan doesn’t cover certain elective or cosmetic procedures or surgeries, the claim won’t be approved. This is called a coverage limit or contract exclusion.

In addition, 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 coverage.

Claims also can be denied for a clinical reason. For example, a service may not be considered medically necessary, or the right level of care wasn't provided given your specific condition. And, sometimes, a 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 inadvertently 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.

How to appeal a decision
Most insurance companies, including BCBSIL, have an internal claims and appeals process that allows you to appeal decisions about claim payment decisions, eligibility for coverage, or ending coverage. Check “adverse benefit determination” in your benefit booklet for information on what appeal rights may be available to you and instructions for how to file an appeal.

If your internal appeal is denied, in some cases you may request an external review. External review is often an option when denials occur related to services that are not medically necessary or clinically unproven. That external review is not performed by your health plan, but rather, an outside entity that will review your circumstances. Please call the customer service number on your member ID card if you have questions about any part of the review process. Your health plan is there to help you find answers.

The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association