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Why Your Health Insurance Doesn’t Pay for Your Dental Care

Understanding the Reasons Under Health Insurance Claim Denial

When a doctor recommends a test, medication, or procedure and your health insurance won’t pay for it, it can be scary. If there are alternative tests, medications, or procedures that will work and your health plan will be covered, then this condition is just an annoying distraction. But, if tests, medications, or procedures are the only thing that will work, the condition can be life-threatening.

When this pre-authorization claim or denial occurs to you, it is normal to get angry and want to fight the denial. However, before you expend your energy for this battle, make sure first of all what is going on and why your health plan is not going to pay off.

While investigating the root cause of your claim denial or denial of your pre-authorization request, you’ll gain valuable insight into the standard of treatment for your particular medical problem, as well as how your health insurance company “thinks”. a more competent warrior if a fight with your health insurance company is needed.

Reasons Your Health Insurance Won’t Pay for the Care Your Doctor Says You Need

1. What you need is not the coverage benefits of your health plan.

When your health plan denies your claim or denies your pre-authorization request for this reason, it essentially says that your policy does not cover the test, treatment, or medication no matter the condition.

Your insurer should know exactly what benefits your policy provides and what is not covered, but sometimes your insurer is wrong . Review your policy carefully. If your health insurance is through your job, check with your employee benefits office to find out if you have coverage for services that your health insurance says is not covered.

In the United States, small group and individual health plans now need to cover significant health benefits, yet large employer -based plans and grandfather plans do not need to provide the same coverage.

If you feel you are being denied coverage benefits your policy says you have, follow your health plan’s guidelines appeals procedure. Also, get help from your employee benefits office if your coverage is employment -based, or your state insurance commissioner if your insurance is not employment -based.

2. You get care from an external network provider when your health plan coverage is limited to an in -network provider.

your coverage is limited to providers in the network that your health plan has a contract with. Your health insurance will not be paid if you use an out -of -network provider.

If you request a pre-authorization and your pre-authorization request is denied because of the provider you selected, you can only resend the request using an in-network provider and not a network provider.

However, if you’ve got care and your health plan won’t pay your claims because you’re out of network, you’ll face a harder struggle on your hands.

You may be successful if you can show that no provider in the network is capable of providing that particular service so you have to leave the network. You may also be successful if you can show that it is an emergency and you go to the nearest provider who can provide the care you need.

3. Your health plan does not consider tests, treatments or medications medically necessary.

If your claim or pre-authorization request has received a medical necessity denial, it sounds as if your health insurance won’t pay because it assumes you don’t need the care your doctor recommended. This may be your health plan, but it probably isn’t.

There are several reasons for a denial of medical necessity that don’t mean your health plan thinks care is unnecessary. To find out what exactly, the denial of your medical needs means, you need to do an excavation. The good news is this digging may show the way to get your pre-authorization request approved, or your claim paid, if you just tweak your approach a bit.

4. Your health plan does not recognize you as a beneficial member, etc. mix.

This type of scenario is more common than most people would imagine. In today’s complex health care system, information about your coverage must flow properly from your employer, insurance broker, or health insurance exchange to your health plan. If there are disruptions or delays anywhere along the way, it can appear as if you don’t have health insurance even though you do.

Along the same lines, it is common for health insurers to outsource to a medical management company to decide on whether or not your test, treatment or drug will be covered. In this case, information about your coverage must flow properly from your health plan to the medical management contractor. Similarly, information about your medical condition must flow properly from your doctor’s office to his or her health plan or medical management contractor. Any error in this flow of information may result in the denial of the claim or the refusal of your request for pre-authorization.

The good news is that a denial of a claim or a pre-authorization prosecution can be quite easily defeated when you accurately understand the problem. 

5. Your hospital stay is not classified as patient observation compared to patient.

If Medicare or your health plan refuses to pay for a hospital stay, the reason may have to do with a disagreement about the correct hospitalization status and not a disagreement about whether you need care. When patients are placed in a hospital, they are given observation status or patient status according to complicated rules and guidelines.

It is common for your hospital and doctor to acknowledge that you should be admitted to a patient condition, whereas Medicare or your health plan assumes you have been admitted to the hospital in observation status. Here’s the catch: if you’re put in the wrong status, your health plan or Medicare may refuse to pay for the entire admission even if your insurer agrees that you need the hospital care provided. It’s a bit like a technical breach.

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