Toll Free 888-357-3226

Guidelines for Claims Denials Due to Policy Limitation

August 25, 2014

Health insurance is a complex business; if your patient has bought a health plan without realizing that his / her coverage doesn’t include a certain medication or treatment, the submitted claim for payment will get denied by the insurer. However, physicians can appeal the denials caused due to health policy limitations.

  • According to the Department of Labor, one claim in seven, made under employer health plans gets denied

Importance of Insurance Verification Prior to Treatment

Physicians need to obtain 100% payment from the patient for providing them services that are excluded from their health insurance coverage. It is extremely important to verify insurance coverage details of a patient before rendering the medical services for avoiding revenue loss.

Both, time and money will be wasted if the billing team avoids the verification process and submits a claim for non-covered services. The insurance company will not only deny payments but the chances of getting reimbursed from the patient will also reduce.

How Does a Health Plan Work?

The denial decisions of a health plan are based on the terms and conditions mentioned in the policy booklet. This booklet has a list of services and procedures that are covered and excluded for eligibility of payments. The items that need to be pre-authorized before the payment are also enlisted in it.

Whenever a payment for a medical procedure or service is denied, health insurance companies forward a denial in writing to the physician as well as the patient, which is called the explanation of benefits (EOB). The written matter explains the reason behind the denials in detail.

Common Denials Related to Policy Coverage

  • Not pre-authorizing medical service or treatment - The medical practice or patient should pre-authorize a medical treatment so that the insurance company can determine if the medical procedure is cost effective and medically necessary. Specialist doctors on the panel of insurance companies verify this.
  • Denials related to timeliness - Majority of health policies have a limited time span within which the claims should be filed. A 90 day period is the initial claims submission timeframe that is generally followed by the insurance givers. The number of times a denial appeal can be submitted to a health plan is also limited.
  • The timeframe ranges anywhere between 95-120 days from the denial date. If a practice fails to submit an initial claim or denial appeal within the mentioned timeframe, the company denies payment and stops considering any further appeals.
  • A denial also occurs if a medical treatment / service was not a covered benefit under the insurance plan. Other reasons include when maximum benefit has been met, possible pre-existing and duplicate claims denials.

Can Outsourcing Help?

In order to minimize the claims denials and obtain timely payments, many practices are outsourcing their billing requirements to companies such as MedicalBillersandCoders.com. The team of certified and experienced billers and coders at MBC is expert at maximizing revenue and maintaining AR days to an average of 21 days. Currently, MBC serves 42 specialties in the US, offering effective billing solutions.

If you have an underperforming billing department, outsourcing can be the best solution to get paid for every service you provide. From insurance verification to using the appropriate codes, skilled billers and coders can help strengthen the financial health of your practice.


Category : Accounts Receivables / Claims Denials