Health insurance claim denials and rejections occur when insurers deny coverage or payment of certain services or procedures. Incorrect or duplicate claims, lack of medical necessity or supporting documentation, and claims filed after the required timeframe are common reasons for denials. Experimental, investigational, or non-covered services are also likely to be denied.
Although there is a difference between a denial and a rejection — the payer makes a denial decision; the clearinghouse, or processor, rejects a claim before it reaches the payer — many people use the terms interchangeably. Since the result is essentially the same, for the sake of simplicity we will use denial to refer to any instance in which a claim is not paid.
When a claim is denied, it’s not necessarily the end of the line. You can make corrections or resubmit the claim with supporting documentation to validate its eligibility for coverage.
Understanding the common reasons for insurance claim denials is crucial to streamlining the reimbursem*nt process and optimizing your claim reimbursem*nts.
Clear and comprehensive documentation is the backbone of any successful insurance claim. Missing or inaccurate details about a diagnosis, treatment, or procedure can cause a denial. Information on or submitted with a claim must be accurate and complete. This includes:
- Patient informationincluding name, date of birth, address, and insurance policy number(s)
- Provider informationincluding name, address, and National Provider Identifier (NPI) number
- Codesincluding procedure (must match the provided service or treatment), diagnosis (must be medically necessary and supported by the medical records), and place of service (must match the location where the service or treatment was provided) codes
- Documentationincluding medical records, prescriptions, and referral forms
COB denials occur when a patient has two or more insurance policies, and there is confusion or lack of clarity about which plan is primary and which is secondary. Many factors can contribute to COB denials, including:
- Complex payer COB policiesthat can be difficult to understand
- Incomplete or inaccurate informationon the claim form, like the patient’s insurance information and the dates of coverage for each plan
- Communication errors between payersto determine and agree on which plan is primary and which is secondary (or tertiary, etc.)
Insurers may deny a claim if they don’t believe the service or treatment was medically necessary or if the provided documentation doesn’t adequately support it — like denying a claim for surgery, stating the patient could be treated effectively with physical therapy. These denials often require appeals to provide:
- Additional documentation that may include medical records, prescriptions, or referral forms
- Comprehensive justifications for any treatments or tests ordered
- Updated or more detailed coding
- More detailed information about the visit or condition
- Information specific to that policy’s coverage criteria
- A “Letter of Medical Necessity” from the physician
Some insurance policies require prior authorization for specific procedures, medications, or medical equipment to be obtained before providing that service or treatment. Examples of services that may require prior authorization include:
- MRI and CT scans
- Certain medications
- Specialist referrals
- Elective surgeries
- Durable medical equipment
Insurance plans have specific guidelines on which services or treatments they cover and which they don’t. Common examples of non-covered services or treatments include:
- Cosmetic or elective surgeries
- New or experimental procedures
- Chiropractic care
- Physical therapy
- Durable medical equipment
- Dental or vision care
- Hearing aids
Most policies also have defined limitations, such as a set number of visits or procedures — for example, a set number of physical therapy visits — allowed per year.
A duplicate claim denial occurs when a claim is submitted multiple times for the same service or procedure performed on the same day. This can happen for reasons such as:
- A provider submitting a claim multiple times by mistake — more likely to occur when claims are sent manually
- A billing software or system inadvertently submitting the same claim multiple times
- Glitches in a payer’s system resulting in duplicate claims processed
You may also see denials for services not paid separately, meaning that service or procedure was included in the payment or allowance for another service or procedure that has already been billed, processed, and paid.
A timely filing denial occurs when a claim is submitted after the deadline, typically 120 to 180 days from the date of service, set by the insurance company.
Reasons a claim may be filed late include:
- Delays in receiving patient informationor other necessary documentation from the patient
- Inaccurate or incomplete claimsreturned to the provider for correction
- Administrative errorssuch as typos or miscoding
- Lack of knowledgeof, or failing to keep up with, the timely filing deadlines for each insurance company (even rare or out-of-state payers)
Many of these claim denials are not the fault of the provider. Even so, there are patterns and metrics you can review to better your processes and decrease your rate of denials. Clear communication, accurate documentation, and staying informed about payer policies are key elements in navigating the complex landscape of insurance claims and avoiding denials. You can also invest in claims management software and training to help you identify and avoid potential denials, or consider utilizing a partner who specializes in complex claims.
Partnering with experts allows your team more time to focus on higher-priority, less complicated claims. EnableComp understands the challenges of complex claim denials and is proficient in denial prevention and resolution. Our team of experts uses proprietary technology and proven expertise to reduce, appeal, and resolve denials, getting you more of the revenue you deserve.
