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Why your insurance company may not pay for your care

When a physician orders a test, medication or recommends surgery, in many cases, the insurance company will be notified for an approval. In some cases the insurance company will not approve the service or procedure for payment. If the insurance company denies coverage/payment, in most circumstances, you and your provider can appeal the decision.

Working with an insurance company to overturn a decision for non-payment or prior authorization can be time consuming and may require working through a complicated and confusing process. Before you decide to appeal a denial first make certain that you know the exact reason for the denial.

There are several reasons why the insurance company may not pay for your care:

  • The service is not considered a covered benefit. If your provider requests payment for a service that the insurance company has deemed “non-covered,” check your policy. If you feel you’re being denied coverage for benefits described in your policy, follow the appeals procedure outlined in the description of benefits provided by the health plan.
  • The physician or hospital that is requesting the approval may be out-of-network. Some insurance plans limit coverage to physicians who are under contract or in-network. If you choose a physician that is out-of-network it is likely that you will be partially or fully responsible for the charges related to the service.
  • The service does not meet the medical necessity guidelines set forth by the insurance company. When a denial is based on “failure to meet medical necessity” it may be the insurer has determined:
    1. You really don’t need the care
    2. There are more cost-effective treatment options that will provide the same outcome as the service requested, or
    3. Existing physician documentation of your condition does not meet the criteria/threshold set by the health plan.

These denials of service or pre-authorization can be relatively easy to overturn, however, you need to be aware of the exact problem. If a health plan denies coverage for a procedure that has already been performed, the cost of the services will likely become the responsibility of the patient.

Health plans maintain a well-defined procedure by which a denial can be appealed. To determine the procedure that needs to be followed for an appeal, refer to the terms of your policy or better yet call the health plan and speak with a member services representative.

SI-BONE has resources available to assist patients with the pre-authorization and appeals process.

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