You've been denied, so what now?
If you've been denied coverage for a service, treatment, medication, etc by your insurance company, it can be a confusing and daunting process. Don't worry, you may have options.
An important step in understanding what these options are is understanding what has actually been denied and why. If your insurer has determined that they cannot approve coverage of some service or treatment, there are many possible reasons why the request has been denied. You should receive a document from your insurer called an Explanation of Benefits. This is a document that insurers are required to provide you by law that explains how each claim or request for service has been evaluated. A sample is shown below:
As you'll see in the highlighted text, the insurer identifies the reason why the claim or service was denied. There can be many reasons for this, including, but not limited to:
- Insufficient information about the requested service
- The requested service is not a covered benefit under your plan
- While the requested service is covered under your plan, you did not meet the insurer's "medical necessity" standard (this is common, and can stem from many causes).