Many claim denials begin at the front desk. Manual errors and oversights in patient data, such as the lack or error of the patient's subscriber number, missing date of birth, and lack of insurance eligibility, can cause a claim to be denied. Most insurance companies allow you to file a claim within 90 days from the time the service was provided. However, some insurance companies only allow a 30-day period.
When a claim is filed too long after the service has been provided, it will be rejected. Make sure you know how much time you have to file a claim, as well as how much time you have to appeal the decision if your claim is denied. Most health insurance companies have a list of services that they don't cover, such as cosmetic surgery, infertility treatment, and gastric bypass. Some plans may also have limitations on the number of services they cover.
For example, a health plan may cover only 30 days of hospital treatment for a given condition. When you file a request for benefits that are excluded or that have exceeded the limits, it will be denied. Insurance companies will deny your claim because of the exclusions in your policy, for example. They can also deny your claim because of suspected fraud, non-payment of premiums, or delay in filing the claim.
Why was your insurance claim denied? Are you worried that your next application will be denied? As you'll remember in previous courses, a rejected request is not the same as a denied one. A rejected request is one that contains one or more errors detected before the request is processed. These errors prevent the insurance company from paying the bill as drafted, and the rejected claim is returned to the invoicer for correction. A rejected request can be the result of a clerical error, or it can be due to a mismatch between the procedure and the ICD codes.
The rejected claim will be returned to the invoicer with an explanation of the error. These complaints are then corrected and resubmitted. It's a good idea to contact the insurance company to understand their health insurance claim process. If you're facing a complicated insurance claim, talk to a qualified and licensed public insurance adjuster for help.
Because your health insurance policy is a contract between you and your insurance company, you must follow the claim process diligently. A waiting period with respect to a health insurance plan means that you must wait a certain period of time to take advantage of insurance coverage. If you don't pay your insurance premiums on time or if you didn't make your last premium payment, the insurer could deny your claim. Stephanie is a property insurance claims expert with more than 20 years of experience working as an insurance adjuster, expert witness, appraiser and arbitrator.
The insurance company or payer may not recognize old insurance cards and identification numbers presented in an original claim. Health insurance claims for certain health insurance plans can present a frustrating level of requirements. You can learn more about the health insurance plans offered by your insurance company by contacting them by visiting their online health insurance site.