The following list of denials are meant to be representative of the denial reasons handled by CMA, but as insurance companies are constantly striving to come up with new denial reasons, this list is not intended to be a complete list.
Not Medically Necessary
When the insurance company feels that the specific treatment rendered was not required based on an alleged medical review of the file. However, often the individual that supposedly reviewed the claim is not a licensed physician or medical practitioner.
Denied For Preexisting Condition
When a claim is denied because the policy language excludes medical conditions that the patient had during a defined period of time before the policy went into effect. The specific restrictions vary from policy to policy.
“Pended” For Preexisting Investigation
When a claim is put on hold by the insurance company while they allegedly investigate whether or not the condition that was treated was a preexisting condition. The insurance company will usually require past medical information from the patient such as a list of doctors that the patient saw prior to the policy’s effective date and those doctors’ records.
Insurance policies usually contain a list and description of certain medical care and treatment that is specifically not covered under the policy.
Similar to non-covered benefits, insurance policies usually contain a list and description of certain medical care and treatment that only have limited benefits (i.e. payment) under the policy.
Termination Of Coverage
When a claim is denied as the insurance company is stating that the patient was not covered under the policy at the time of treatment. This often occurs even if the insurance company verified benefits to the hospital upon admission. (Sometimes the insurance company will completely rescind the policy, thus backdating the policy and treating it as if it never went into effect.)
Failure To Obtain Pre-Authorization
Most insurance companies require either the individual or the medical care provider to call and obtain prior authorization of a particular treatment. If this is not done, the insurance company will deny a claim or assess a financial penalty.
Treatment Does Not Match The Authorized Days
When the treatment is different than the days authorized, some insurance companies will deny the entire claim on the basis that the number of days authorized do not match the number of days on the hospital bill.
When a claim is denied or benefits are reduced because the patient did not seek treatment from a medical provider listed by the insurance company as part of their network of providers.
Treatment Could Have Been Provided At a Lesser Level Of Care
When a third party reviewer, normally for the insurance company, feels that the treatment provided was excessive under the circumstances and that lesser treatment could have been provided.
When the insurance company feels that the course of treatment was not sufficiently medically established to warrant coverage.
An insurance company will deny a claim if it suspects that the injury or illness may have been work-related. This would alleviate their financial responsibility by forcing workers’ compensation insurance to cover the charges.
Pending Receipt Of Completed Claim Form
This is a favorite tactic of many insurance companies. They will deny or pend the claim until a claim form is completed by the insured. They will often state that it is required that their members update their records and refuse to process the claim until such information is received.
When an insurance company will deny a claim based on their time requirements for the filing of a claim after discharge. The time requirement may be in the patient’s policy or in a contract the insurance company has with the hospital.
Appeal Time Expired
For this denial, the insurance company refuses to consider a hospital or their representative’s appeal of an earlier denial as the insurance company is claiming that it was filed after the insurance company’s appeal deadline. As with untimely filing, the time requirement may be in the patient’s policy or in a contract the insurance company has with the hospital.
Denied For Alcohol Use Or Commission Of Crime
When an insurance company denies a claim based on alleged language in the policy with their insured where it states that injuries resulting from certain type(s) of illegal activities are not covered. Exact language varies among insurance companies and even among policies, but what is consistent is that usually the denial is based on the patient’s conduct at the time of injury.