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Doctor With ClipboardYou had a medical procedure or a doctor's appointment. You assumed your health insurance covered the costs. Then, you receive a letter in the mail telling you that your insurer has denied your benefits. A denial of benefits can happen for many reasons. It's up to you to ensure that any and all of the procedures and appointments you have are covered under your plan or, if not, that you plan to pay for them out of pocket. However, there is not always enough time to do that. It may have been a simple oversight. In most cases, you may have the ability to appeal these decisions. However, it's important to understand why a denial of benefits can occur.

The Charges Weren't Covered


The most common reason for denials is because of a non-covered charge. Why would your insurer believe you didn't need the care? This depends on the details of your policy, but most often it's because they lacked information or a reason for your medical need. If your medical care is not considered medically necessary or the treatment is considered experimental, these are common reasons for denials. In some cases, additional information is necessary for the insurance provider to make the right decisions. In other cases, it may not be covered.

Preauthorization Wasn't Obtained


In some situations, such as when visiting a specialist, you will need to contact the health insurance provider first and request that you are given authorization to receive the care. You may need a referral from your primary care doctor. If you did this and still received the denial, it may be a clerical error.

You Went to the Wrong Provider


In some types of health insurance plans, you need to obtain care from an in-network provider. These are groups of care providers that are affiliated with the insurance agency. This is common in HMOs. If you went to a doctor that is considered outside of your HMO, your care may not be covered by your insurance.

In addition to this, you may have other mistakes occurring, such as minor errors in the documentation and categorization of procedures. The wrong insurance provider may have been billed. If you receive a denial of benefits, call your insurer to find out why and consider upgrading your insurance to better meet your needs.

Ensure your policy meets your needs. Call TCU Insurance Agency at (800) 772-8043 for more information on the health insurance options we offer.
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