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Insurance Payment Problems

One of the biggest insurance headaches is having a medical service denied by the health insurance carrier. The reasons health insurance bills get denied by the insurance carrier could be many. The trick to getting insurance to pay the medical bill is to understand the common reasons for denial and how to challenge the insurance carrier.

  1. No Pre-Authorization

    • This denial occurs when you go to a specialist without getting a referral or authorization from your primary care physician with a traditional HMO health plan. This denial also occurs if the health insurance carrier requires authorizations for inpatient admissions, and one was not made by the patient or physician.

      If you did not get a referral or prior authorization, you may be responsible for the bill.

      To eliminate this type of denial for payment, call the billing company for the physician or hospital, and always document and file the authorization prior to receiving the services.

    Not Medically Necessary, Experimental, Not Covered

    • Not "medically necessary" and "not covered" are denials if the provider performed a procedure the health insurance carrier deemed not necessary for the condition the physician stated.

      To resolve this denial, have the provider write a letter or an appeal to show why the service was necessary. Call the carrier to determine if you are really responsible for the bill, even though the "not medically necessary" services were rendered to you already. Ask the insurance carrier representative to show you where the policy states that this service is not covered or not medically necessary, and ask who is responsible for the balance, you or the physician.

    Additional Information Requested

    • If your health insurance carrier gets a bill from a doctor or hospital, and the bill is missing necessary information, insurance will not pay the bill. The bill will be sent to you for payment.

      You resolve this by sending the billing company the information about what is missing (dates of birth of members, any other health insurances you are covered under and proof of coverage for students over 18).

      The physician or hospital (billing office) is responsible to send the carrier information when a denial for missing information (member ID numbers, group numbers, procedure codes, diagnosis codes, medical notes, referring physician, last monthly period, etc.) occurs.

    Covered by Other Plan

    • Payment is not made because this service is covered by another plan.

      This type of denial happens when the health insurance company believes that the service should be paid by auto or workman's compensation insurance instead of the health plan. If the bill should be paid by another plan, submit that information to the physician or hospital billing company for them to submit to the correct plan.

    Need to Know

    • A message that states the bill balance is Over and Above Reasonably & Customary Charges is not a denial. This information is given when the health insurance carrier pays a portion of the medical bill and the remaining balance is what the company considers to be excessive for such a procedure. Most physicians and hospitals have to accept what was paid as on the bill as part of the agreement with the insurance carrier.

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