Reasons Behind the Denial Of Medical Claims

To avoid denials of medicare claims, understanding the reason for denial is the most important thing. Medical claims denial happens when your insurance provider wants to avoid paying for some reason. If this situation happens after you have received medical service and also you have submitted the claims, this is called claims denial. Sometimes your insurance company does not want to pay for a certain service at the time of the pre-authorization process, these types of denials are called prior-authorization denials. In both of these situations, you may appeal and for your appeal, the insurance provider also has to reverse its decisions and have to pay for the services that you want. 

Why Would A Medical Claim Be Denied?

Why Your Health Insurance Can Be Denied?

There are over hundreds of reasons behind the cancellation of insurance for denials in medical billing. Some reasons are quite easy to solve but some are a bit difficult to find a solution. 

Some Common Reasons Behind Rejected Medical Claim Includes:

Mix-ups or paperwork errors

Sometimes these situations happen, for example, the healthcare provider gave documents named John Q. Ashle but the insurance provider writes your name as John O. Ashle in your medical documents then for these mistakes, you will not get your claims because of the wrong name. 

The necessity of the medical claim

The insurance provider sometimes believes that the requested claim is not quite medically necessary.

The two possible reasons behind this are

  1. The service that you have requested is not that vital or necessary.
  2. You require the service but for some reason, you cannot convenience the reason of your requirement to the provider. For that, you have to provide more details to the insurance company to be convinced. 

Cost control

The third reason behind medical claim rejection and denials is sometimes the insurer wants you to find an alternative, less expensive option first. They will approve later but first, you have to try another alternative way out.

The Service is not included in your plan

The service that you have requested is not under the covered benefit. These types of reasons behind denied claims are quite common in cosmetic surgery and non-approved FDA treatments. It is also commonly seen for all of the healthcare services that do not tend to fall within the state’s definition of the essential health benefits, however, if the plan you are using has been obtained in a small group market or individually it can include chiropractic or acupuncture services. 

There are some gaps in covered benefits which are quite common when you have bought a plan which is not regulated by the Affordable Care Act rules and thus many services are not covered which you expect like mental health supervision, prescription drugs, maternity care and much more.

Network issues

The structure of your healthcare system will determine how much claim ratio of health insurance you can get from all the services that you have provided to your patients. Thus if your claim does not include in the plan, the provider can deny your claim.

Missing details

In some cases, the company can deny if you do not provide the insurance company with enough details about your claim. For example, you are going to do an MRI scan of your foot but your healthcare provider does not share any details about what happened with your foot to the insurance provider, can deny your claim.

Following the health plan’s rule

For instance, if your health plan requires pre-authorization for any particular non-emergency test and let’s say you have done the test without any pre-authorization. In that case, your insurer has the full right to deny your claims, even though you need the money, still, you will not get that because you have not followed the rules that were instructed in the medical billing rules. 

That is why for any non-emergency cases, the best thing is to discuss with your medical insurance provider each and every rule that you should follow to get your claims successfully passed through because these types of mistakes impacts medical claims processing and can be quite detrimental for the hospital business that you are running. 

Following the health plan’s rule

For getting all the claims after your healthcare procedures, there is a certain time limit that must be followed. Within that time you have to submit your papers to the insurance company for the claims. That is why it is better to set a reminder because as the time limit is approaching you will get alerts.

Did you unbundle or upcode?

The use of medical billing codes for getting medical reimbursement for a service that is a bit on the costlier side rather than what has been performed is called upcoding. Bill the services separately but in a way that they should look like they are together is called unbundling. If you use any of these techniques, your claims can be denied.


Generally, nobody likes to spend their time working on the denied claims as it takes a long time and procedure to get the payments back if possible. But, fortunately, there are ways where you can minimize the amount of risk to happen. To minimize the number of claim denials there are a few ways like, the healthcare providers have to have good communication with both the insurance provider and the patient, coding professions who are well trained is required, good staffs who usually sit at the front desk and a very good healthcare system software to run each and every detail smoothly and in a hassle-free way. 

These are the things that should be followed both by patients and the healthcare industry for the prevention of claim denials and headaches during getting the claims.