Living

Living: 17 Reasons Why Your Medical Claim Was Rejected


By Stephanie Banks

Healthcare is an important human need and when you fall ill, you expect that your insurance will cover your medical costs and settle the bill presented to them. Unfortunately, not all claims are accepted and yours could be one of the rejects. This is devastating and to avoid a repeat of the misfortune, you should know the reasons for rejection. They include:

  1. Delay in filing for the claim

Do not wait too long to file the claim. Most insurance companies give 60 to 90 days from the time you were to file the claim. Waiting too long for submission of the claim to the EDS before submission to the insurance company leads to rejection.

  1. Use of incorrect codes

Every medical biller and billing coder knows the rules on coding for processing the insurance claims. However, the wrong codes could be entered and sent to the insurance company. In such cases where the diagnostic and procedural codes are incorrect or missing, invalid, or if the codes do not correspond to the treatment rendered, your claim will be rejected.

  1. Preauthorization

If services are provided without the right authorization, the insurance company will refuse to give payments for the claim presented to them. Preauthorization is a necessity for most insurance companies and insurance plans.

  1. Loss and expiry

If the insurance company loses the claim presented to them as a result of misplacement then find it, but the claim is expired by the time it is fed into the insurance company’s system, your insurance claim will be denied.

  1. Provision of two services within a day

Unfortunately, insurance companies have a very strict rule on the number of times you can receive services in a day. If you get two services or go for two sessions within a day, the insurance company will reject the claim for the second session and only approve the claim for the first session of that day.

  1. Services completed at the wrong location

Doctors and medical practitioners and hospitals are required to provide the list of their offices or places they serve their clients from. This is a requirement by many insurance companies. If the company fails to do this and you are served at one of the unregistered locations, your claim will be rejected. Doctors should have medical billing applications that show where they work and if registered. Anesthesia services, Ltd provide such details.

  1. Absence of referrals from a doctor

Besides authorization, insurance companies need referrals from your primary care provider before services are rendered. If the services are rendered before the referral is confirmed by the insurance company, they will reject your claim.

  1. Loss of your insurance cover

If you lose your insurance cover, your claim will be automatically rejected by the insurer after billing is done and claim submitted.

  1. Change of insurance plan

If you change your insurance plan, your doctor should ensure that they are networked in the new plan and they should have a new preauthorization. Failure to comply leads to rejection.

Other reasons for rejection:

  1. Late payment of COBRA
  2. Timed-out authorization
  3. Claim sent to the wrong managing company
  4. Provider not paneled with the insurance company
  5. Services already rendered
  6. Out of state insurance plan
  7. Difference in out-of-network and in-network benefits
  8. Doctor out of authorization sessions

In conclusion, your claim gets rejected for any of the above reasons. Ensure that you and your doctor comply with the rules.

Author Bio: Stephanie Banks is a medical billing expert at the anesthesia services company. She loves to dance and teaches dance lessons to kids when she isn’t working.


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