{"id":355852,"date":"2017-01-13T11:22:35","date_gmt":"2017-01-13T16:22:35","guid":{"rendered":"https:\/\/content.findlaw-admin.com\/ability-law\/healthcare\/patient-rights\/what-to-do-if-your-health-insurance-claim-is-denied.html"},"modified":"2023-06-28T12:47:52","modified_gmt":"2023-06-28T17:47:52","slug":"what-to-do-if-your-health-insurance-claim-is-denied","status":"publish","type":"page","link":"https:\/\/www.findlaw.com\/healthcare\/patient-rights\/what-to-do-if-your-health-insurance-claim-is-denied.html","title":{"rendered":"What To Do if Your Health Insurance Claim is Denied"},"content":{"rendered":"\n
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What To Do if Your Health Insurance Claim is Denied<\/h1>\n
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\n By Melissa McCall, J.D.<\/a> | Legally reviewed by Aviana Cooper, Esq.<\/a>\n | Last updated\n
\n \n <\/i>\n Legally Reviewed\n <\/summary>\n\n
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This article has been written and reviewed for legal accuracy, clarity, and style by FindLaw\u2019s team of legal writers and attorneys<\/a> and in accordance with our editorial standards<\/a>.<\/em><\/p>\n\n <\/div>\n <\/details>\n\n

\n \n <\/i>\n Fact-Checked\n <\/summary>\n\n
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The last updated date refers to the last time this article was reviewed by FindLaw or one of our contributing authors<\/a>. We make every effort to keep our articles updated. For information regarding a specific legal issue affecting you, please contact an attorney in your area<\/a>.<\/em><\/p>\n\n <\/div>\n <\/details>\n<\/section>\n

Consumers have options if their health insurance claim is denied. Although a denial can threaten their financial security and ability to access medical care, it is not the end of the story.<\/p>\r\n

Most Americans access health care through health plans. Many companies offer health insurance as part of their benefits packages. Low-income Americans or the self-employed can get insurance through the Affordable Care Act<\/a> (ACA).<\/p>\r\n

Health insurance companies offer plans on the federal exchange,<\/a> and consumers can purchase an appropriate plan.<\/p>\r\n

Some providers do not accept any health insurance plans, and this is one scenario where consumers have to submit claims. The consumer has a doctor’s visit and pays out of pocket. Then the consumer submits a receipt to the health insurance company for reimbursement.<\/p>\r\n

In other cases, the provider submits a claim to the health insurer after the visit. If the insurer denies the claim, the patient is responsible for the claim amount.<\/p>\r\n

In both scenarios, the insurer can either approve or deny the claim. If they approve the claim, the bill is paid. If not, the consumer can appeal the denial.<\/p>\r\n

Understanding Health Insurance Claims<\/h2>\r\n

Whether consumers get health insurance through their employer, the federal government (Medicare<\/a> and Medicaid<\/a>), or on a federal exchange, it is crucial to understand their insurers’ policies.<\/p>\r\n

After obtaining insurance coverage, consumers will get a copy of the insurance policy. This policy should outline the premiums, if any, and what medical services are covered. Health insurers prefer to cover medical services from health care providers in their network. These providers are under contract with health insurers. They agree to a fixed rate. They are also listed in the insurers’ directory.<\/p>\r\n

Providers not in their network are out-of-network providers and can charge their rate for services. An insurer’s coverage of out-of-network coverage is outlined in their policy. Prior authorization is one option for out-of-network coverage. The consumer or the provider submits a request to the insurer before the visit for approval.<\/p>\r\n

Another option is for the provider to bill the insurer directly. The bill will include information about the visit. This is the health insurance claim. If the insurer denies the claim, the patient is responsible. If the provider does not take insurance, the patient will pay for the visit and submit a claim afterward.<\/p>\r\n

In each scenario, the health insurer can approve or deny the claim.<\/p>\r\n

Health Insurance Claim Denial Reasons<\/h2>\r\n

The first step in determining options after the denial of a claim is to ask why? Why was the consumer’s claim denied?<\/p>\r\n

Many insurers send consumers an explanation of benefits (EOB) after their claim is processed. If the insurer denies the claim, the EOB will explain the reason for the denial. Other insurers may issue a denial letter with reasons for the denied claim.<\/p>\r\n

A few common reasons for health insurance claim denials include:<\/p>\r\n