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:
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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