Whether your healthcare plan denies a claim for a medical service you’ve already received or it denies a pre-authorization request, getting a medical denial is frustrating. But a denial doesn’t mean you’re not allowed to have that specific healthcare service. Instead, it either means that your insurer won’t pay for the service, or that you need to appeal the decision and possibly have it covered if your appeal is successful.
If you’re willing to pay for the treatment yourself, out-of-pocket, you’ll perhaps be able to have the healthcare service without further delay.
If you don't have enough money to pay out-of-pocket, or if you’d rather not, you may want to investigate the cause of the denial to see if you can get it overturned. This process is called appealing a denial, and it can be done in response to a prior authorization denial or the rejection of a post-service claim.
All non-grandfathered healthcare plans have a procedure in place for appealing denials, which was codified by the Affordable Care Act 8 (grandfathered strategies will usually have their own appeals process, but they don't have to comply with the ACA's specific requirements for an internal and external appeals process). The appeals process will be outlined in the information you receive when you’re informed that your claim or pre-authorization request has been denied.
Follow your healthcare plan’s appeals procedure carefully. Keep good records of each step you’ve taken, when you took it, and who you spoke with if you’re doing things on the telephone. In most cases, your healthcare provider's office will be closely complicated in the appeals procedure too, and will handle a good chunk of the essential documentation that has to be sent to the insurer.
If you’re not able to resolve the issue by working within your healthcare plan, you may request an external review of the denial. This means a government agency or other neutral third party will review your claim denial (there is no guaranteed access to an external review if your healthcare plan is grandfathered, but the strategy may still offer this voluntarily).
Summary
There are a wide range of reasons for claim denials and prior authorization denials. Some are due to errors, some are due to treatment issues, and some are due to a failure to follow the steps required by the healthcare plan, such as prior authorization or step treatment. If a claim or prior approval request is denied by a healthcare plan, the decision might be reversed when additional information is provided to the healthcare plan, or following a successful medical appeal.