denial of claim

What is a denial of claim?

Denial of claim is the refusal of an insurance company or health plan to cover the cost of treatment that has been provided by a health care professional.

Denial of a claim is not the same thing as a claim being covered but billed to the patient because they haven’t yet met their deductible. For example, if your health plan has a $5,000 deductible and you go to urgent care for stitches, you might get a bill for $1,000 and your insurance might pay $0. The explanation of benefits (EOB) in this case would clarify that the $1,000 is being applied to your deductible (which means you have to pay it) and the health plan isn’t paying anything. But this doesn’t mean the claim was denied. It was still covered, but your plan’s cost-sharing requirements and the fact that you haven’t yet met your deductible will result in you having to pay the full bill.

A claim denial is also not the same thing as denial of a prior authorization request. Prior authorization is requested before a medical service is provided, while a claim is submitted to the health plan after the medical care has been provided.