Your Health Insurance Claim – DENIED!!!

Have you ever received a denial letter regarding your health insurance coverage?  Do you know of someone who has?  Unfortunately this happens more than I would like to see. 


 A couple of reasons for denial of your healthcare insurance claim are:

  • Documentation did not support the diagnosis or the treatment billing
  • Diagnosis is not covered under your insurance policy – The Exclusions

I should note this is not an exhaustive list. This second one is interesting.  Most of us do not read the exclusions in our insurance policies.  When we sign up we make sure that what is important to us at the time is included in the policy.

One of the most common problems I notice in my Patient Healthcare Advocate work is that a diagnosis  written down on the medical record  without the supporting diagnostic tests or assessments.  The insurance company reads the diagnosis and determines your coverage for that claim is  “DENIED based on Exclusion # ….. of your policy.”

Sometimes these situations have relatively easy solutions such as a letter to the insurance provider accurately pointing out the disconnect in the medical record for the diagnosis.

For the sake of simplicity I will use one of the more common denials.  Some insurance companies deny claims if they believe someone is alcohol or drug intoxicated. The Physician, Physician Assistant, or Nurse Practitioner, might write a diagnosis that says: “ETOH intoxication.” If this were the case you would expect an alcohol blood screen order and result on your medical record.  However often I see the diagnosis without the blood test.  Here is your disconnect. The insurance company reviewer simply saw the diagnosis but did not review for supporting data. The reviewer write “DENIED based on Exclusion …. “.

“Connecting the dots”, as I call it, to show the insurance company that there was no testing done to support the diagnosis is a key step to getting insurance to cover the bill.

I am sure you know what your health insurance policy covers. Do you know what the exclusions are in your healthcare insurance policy?

More on this topic another day.

Have an awesome day!


“Navigating Your Way Through Our Healthcare System.”

About Donna M. Post, RN CLNC/Mid-Valley Legal Nurse Consulting, Inc.

Donna M. Post, RN, BSN, MBA/HCM, CLNC, LNCP-C is a Registered Nurse with 25 years of experience ranging from critical care to healthcare management. She currently is a Certified Legal Nurse Consultant and Certified Life Care Planner and the founder of Mid-Valley Legal Nurse Consulting, Inc.
This entry was posted in General, Health Inurance, Patient Advocacy, Uncategorized. Bookmark the permalink.

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