Patients need to know that there is a difference between the denial of a health insurance claim and the rejection of a claim. Claim rejections occur when a claim is not even processed by the health insurance company. Rejections are “kicked out” immediately after they are electronically uploaded and before any type of coverage determination is made Benefits of Using.
The electronic submission systems have “claim edits” that catch bad data based on demographics, age, gender, and basic insurance information. Rejections are cause by things like submitting incorrect policy numbers, enrollee numbers, patient birth dates, or sending the claim to the wrong insurance company.
Rejections require that the patient and the provider re-verify all of the information that is submitted to the insurance company and then re-submit the claim. Denials on the other hand, occur when the health insurance company receives and processes a claim,
But determines that the treatment in question is not a covered benefit in the benefit plan. Denial codes on the insurance notices that come back will include a message like “service not a benefit in enrollee’s plan”, “denied for lack of medical necessity” or “denied coverage of experimental treatment”. Denials can be appealed if a mistake has been made and a decent portion of denials are overturned.
Incorrect policy number, enrollee number, or patient birth date
If you receive a notice from your health insurance company indicating that there was an incorrect policy number, enrollee number, patient birth date, or “no record of coverage” then the claim that your physician or healthcare provider sent to the insurance company did not accurately identify who you are. This is the number one reason for rejected or denied claims and it is very common.
Service not provided during enrollment period
Your employer buys health insurance every one to two years. Services that overlap these renewals periods are prone to errors. If your employer changes insurance companies, you have to be well aware of the effective dates and make sure your providers are well aware of the changes. Also, take note of the length of time before your health insurance becomes effective when starting a new job.
Service not a benefit in the enrollee’s benefit plan
Your employer looks at many health plans and weighs the cost of the plan against the benefits and services included. Unfortunately, employers sometimes have to make tough decisions and cut certain benefits for the sake of others. What is even more unfortunate is that most employees, including me, never take the time to see what is included in their benefit plan until it is too late.
The benefit plan is the document issued by your insurance company that describes what services and covered and the corresponding coverage level. You could think of the benefit plan as the contract between you and the insurance company.
You pay them premiums and they provide health insurance benefits that are clearly spelled out in the benefit plan. If you get a notice from a healthcare provider or an EOB from your insurance company that states “service not a benefit in enrollee’s plan” the first thing to do is check the benefit plan to make sure.