How to Track Insurance Denials

Insurance denials occur for pre-authorization requests or at the time of claims processing. Pre-authorization for treatment is required for certain procedures, treatments, hospitalizations and medications. The insurer reviews the request and authorizes, denies or partially approves the request. Submitted claims may be denied for any of several reasons, such as lack of medical necessity, missing information or benefits that are not covered by your plan. Keeping track of denials is important, especially if you plan to appeal the denial or file suit against the insurer or your provider.

Instructions

• 1

  Save the Explanation of Benefits (EOB) statements sent to you from your insurance company. An EOB is sent each time a claim is submitted. The EOB shows information about the denied claim, including the service or procedure for which the claim was submitted, the dates of service, the provider name, the payment (if any) and the reason for the denial.

• 2

  Review any denial letters sent from the insurer. With an insurance denial, the insurer typically mails you a letter that lists very specific reasons for the denial. If the claim is denied for lack of medical necessity, an insurer may list the specific criteria not met. The letter also outlines appeal rights and the contact that can furnish you with more information. A copy of this letter goes to your provider.

• 3

  Call your insurance company to inquire about insurance denials. You can find out the details of the denials and take notes to track each one, if there are several. The representative can relay your appeal rights and give you the opportunity to file an appeal by phone. You may find that the denial is for an administrative reason, such as exhaustion of benefits, reaching your limitation for certain services or information missing from your claim.

• 4

  Look at your claims history on the member portal of your insurance company's website. Some insurers offer a confidential portal that allows you to set up a login to access information about your covered benefits and claims. The site may have records of your claims and what was denied and the ability to download and print this information.

• 5

  Keep all written documentation of your insurance denials in one folder in your home office; store the documentation with other important paperwork. Place all EOBs, denial letters, benefit information and records from your phone conversations into a manila folder for easy reference, should you need to refer to this denial information later.