How to Prevent Your Health Insurance Provider from Denying Your Claim

You need pre-authorization or a referral 

Did you need to undergo a medical procedure such as an MRI or a CT scan? If so, your insurance provider may require a referral or pre-authorization from your physician.

Even if the facility agrees to provide the procedure without a referral or pre-authorization, your insurance provider may not agree to cover the cost. To rectify the situation, see if your doctor can reach out to your insurance carrier and let them know about ordering the procedure for you. (Physicians and other healthcare specialists using services like Fortis Medical Billing may have an easier time working with your insurance carrier.)

Your policy does not cover the procedure

Even with proper pre-authorization or a referral, you must check with your insurance provider or look over your policy to ensure your plan includes the procedure. Even if your carrier previously covered the procedure, your latest plan may not include it. 

You used an out-of-network provider

Something else to double-check on your insurance plan is whether the provider you want to see is in your current provider network.

Provider networks are common for exclusive provider organizations and health maintenance organizations. If you do not use an approved provider who agrees to your carrier's payment terms, your insurance carrier may deny your claim. Occasionally, insurance companies will accept a claim from an out-of-network provider, but you may have to pay a higher percentage of the costs than you normally would.

If you want to have the option of using out-of-network providers, ask your current carrier if you can include out-of-network benefits on your current health insurance plan. That way, you receive non-emergency and/or elective treatment. 

Your claim contains typos

A clerical error on your part may be the reason for your denial. Check to see whether you listed your birth date, name, address, and all other personal information correctly on your claim. If you notice a typo, reach out to your provider's customer service department to correct it.

Your physician billed the wrong provider

Perhaps the mistake was your doctor's and the wrong insurance carrier received your claim. This sometimes happens if you go to a doctor or another healthcare provider you have not been to in a while. They may have outdated or inaccurate policy information on file. 

Do you have multiple health insurance...

Keep reading on Quick and Dirty Tips