Top 3 Reasons Insurance Claims Are Denied

Rohan Mathew

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Top 3 Reasons Insurance Claims Are Denied

Insurance can be an amazing thing when it works well and is not denied for one reason or another. In 2021, approximately 52% of Americans owned insurance. As many as 18% of all insurance claims are denied for one reason or another, but most of the denied claims have a few very specific reasons for why they were tossed out for coverage.

From a patient point of view, any denied claim can be frustrating. When the denial is based on human error, misunderstanding, or computer snafu, it’s even more annoying. Take a look at some of the reasons why coverage might be denied, with the possible solutions that could rectify the situation.

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Incorrect Information

With how convoluted and complicated as a patient’s health records and information can be, it’s not surprising that one of the biggest reasons for insurance denial is faulty information. It could be that your name was spelled incorrectly. Perhaps your date of birth was transposed or mixed up with the one from a different patient. It could be that it’s just that your social security number is mixed up, transposed, or mistyped. One of the common errors happens when your group number is missing or incorrectly entered.

Solution: While the error could happen in any number of ways, the solution is pretty consistent. You must verify your patient information when you go for every doctor appointment or visit. Be sure to fill out all your demographic and insurance information, but also check to make sure that they have all the correct information in their system, including a copy of your insurance card, your driver’s license, passport, and other identifying material. Even if you’ve checked your personal information and records in the past, you must still verify that demographic and insurance information. It’s always possible that errors could have been introduced into your record any number of ways.


Another common reason for the denial of insurance coverage is because your coverage was terminated. It could be that you’re changed jobs, or your coverage has been switched to a different insurance provider. Just as frequently, though, it could be a mistake in entry or a mistake in the end or start date of coverage. Mistakes and errors can be a big part of why terminations are reported, leading to denial in your insurance coverage. It would be nice if the solution was as simple as it appears to be for termination to be reported.

Solution: It’s easy enough to say that you can just verify your insurance coverage and benefits. If there’s ever a question of coverage, or you want to make sure there isn’t an issue, you can call your insurance company prior to going in for your appointment to make sure everything is sorted out. Even when you do call and check, though, there could always be a snafu between the doctor’s office and your insurance company. The best solution is to just keep on working on it, call both the doctor’s office and your insurance provider to make sure the issue is resolved. If the issue is ongoing, request documentation that confirms coverage, which you can then share with your doctor’s office or care provider.

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Lack of Coverage or Prior Authorization Required

It could be that the procedure is not covered by your insurance, or you need prior authorization prior to receiving the treatment. In many cases, you can determine your coverage options by reviewing the details of your policy with your insurance provider. Axis bank rtgs form. Your policy coverage information is often available via the online portal, which may also include your medical history, records, etc. If you have questions about what your coverage document means or how it applies to your particular situation, you can reach out to an insurance attorney to learn more.

Solution: When your coverage has been denied due to lack of coverage or the lack of the required prior authorization, you can contact your insurance to confirm the details of the denial. If you feel the denial is in error, based on the policy details you’ve reviewed, you can request clarification. It could be that you’re not aware of a policy change, or your doctor’s office may have simply misunderstood the coverage you have. Whatever the cause for the denial, you first must determine whether the denial is valid, based on your existing coverage. But you also must check with your doctor’s office and your insurance provider to verify that prior authorization is taken care of, as appropriate.

Next Step: Schedule a Consult with Your Insurance Lawyer

If your insurance claim has been denied, and you’ve already attempted to resolve the situation via other solutions, you don’t have to give up. Insurance lawyer Doug Terry has the experience and skills you need to navigate the health care system. He understands the claims process, but he also recognizes everything that can go wrong and how to fix the most common problems.

An insurance attorney can take on the insurance company and make sure that they don’t take advantage of you. When they are clearly misusing the policies and procedures to the detriment of your health and well-being, an insurance lawyer can advocate on your behalf to make sure you get the comprehensive care you need and deserve. And if you’re still not getting the care or coverage that you’re owed, the insurance attorney can represent you and demonstrate how bad faith is involved in the case and get you the compensation you’re owed if appropriate.

You may not even know what you need until you’re in the midst of a very difficult situation with your insurance company. That’s why it’s a good thing that insurance attorneys are standing by to offer advice, walk you through the entire process, help you understand what your options are, and get you the best possible outcome. Whether it’s a simple error or something more insidious, we’re standing by to make sure that you are not facing your insurance company alone with all those calls, letters, emails, and other communications.