Identifying the Reason for Denial

Identifying the Reason for the Denial

Health Company must evaluate each report for patient and policy recognition and compare the data with itis computerized database.Health insurance shall include the reason for the denial of payment of the service as well as the means of appeal of the decision. How an insurance provider declines to reimburse a premium or a contracted claim. There is a number of  reasons why the claim is denied:

♦ The facility was not covered by the contract for health care of the patient.

♦ There was another insurance company that's the primary.

♦ The procedure or service rendered is covered by a different procedure or service being paid at the same time.

♦ The patient's policy has been terminated with NO COBRA continuation.

♦ The policy of the patient is recent and not valid on the date the services were provided.

♦ Authorization or pre-certification was not received prior to the rendering of the service.

♦ Treatment are considered not medically required Services are no longer suitable for a particular health care environment or quality of treatment Facilities are considered to be new or for an investigation into this condition.

♦ Effectiveness of medical care has not been confirmed.

Patient is not qualified for the coverage offered by the insurance program.

Denials will be checked and appealed if the rejection is wrong on the grounds of documented evidence supporting the appeal.