Do You Know Why Your Insurance Claim Has Been Denied?











Many often you may find that your insurance claim which was made by you has been denied. If you know what are the various reasons due to which the medical claims are denied by the insurance companies, then you will be careful about it in the future. Therefore, in this article we shall talk about few good reasons due to which your claim may be denied.

  • Incorrect details about the patient

One of the major reasons of insurance denial is that the information to identify the patient is not accurate. Unless you provide an accurate information about the patient, it can create confusion and as a result your claim is denied. Most common mistakes are as follows:

  1. The name of the patient spelled incorrectly
  2. Date of birth of the patient does not match with the record of insurance plan
  3. Subscriber number may be missing or invalid
  4. Subscriber group number may be missing or invalid
  • Insurance coverage is inactive

It is important to know whether the insurance policy is still active or not while making the claim. Due to a number of reasons the insurance policy must have been terminated.

  • May need prior authorization

Many cases which are not emergency in nature need prior authorization before taking the treatment from the doctor or hospital. Certain expensive services like MRI, CT scan, Ultra sound or surgical procedure needs prior authorization from the insurance company.

  • Certain services may not be included in policy

Certain medical services that the patient must have taken may not be included in your medical policy and for those services patient need to pay on their own. Therefore, patient must be aware about the services which are included in the policy.

  • Absence of medical records

For making certain medical claims, the health insurance company require few old records. Some of the following documentations are usually asked for:

  1. Medical history of the patient
  2. Physical reports
  3. Doctor’s consultation records
  4. Radiology reports
  5. Operative records
  6. Patient discharge summaries
  • Coordination of benefits

This kind of denial may be due to any of the following reasons:

  1. Other insurance may be primary
  2. Missing estimate of benefits
  3. Information about other insurance has not been submitted
  • Bill liability carrier

If you have made claim under the auto accident or work-related accident then some insurance may deny the claim unless the auto insurance or worker’s compensation insurance is billed. For any accident related cases, the following third-party liability insurance should be filed as primary insurance.

  1. Auto insurance policy
  2. Worker’s insurance policy
  3. Malpractice insurance
  4. Home owner’s insurance
  5. Business liability insurance
  • Invalid or missing CPT or HCPCS codes

Certain codes like Healthcare Common Procedure Coding System (HCPCS) must be given correctly in order to process the medical claims. Make sure that you have provided your updated codes while submitting your claim.

  • Timely submission

There is certain time specified deadline for making the claim and if your claim date is too late after the specified period then too your claim may be denied.