At times we will have an insurance company deny a claim that we have reviewed or appealed. 

Once we receive a denial back from the insurance company, we need to determine what needs to be done:

First we look at what is the reason for the denial. Some of the more common reasons are:

  1. Some part of the claim is not covered
  2. Needs authorization
  3. Needs medical records
  4. Looking for insurance update from the client
  5. The insurance just processed the claim incorrectly

Next, what needs to be done in order to get the insurance to pay the claim:

  1. A call to the insurance
  2. A call to the clients family
  3. Fax or submit a review
  4. Reaching out to the therapists for a Letter of Medical Necessity

Once we determine what needs to be done, we send a review or call the insurance company to have the claim reprocessed.  This usually takes 30-45 days for reprocessing. If the claim is not reprocessed, we will continue to work on the claim until we can resolve it. 

The difference between the deductible, coinsurance and copayment:

  • Deductible is an amount on the insurance plans (varies for each plan) that must be met first before the insurance company will start paying on claims.
  • Coinsurance is the amount (varies for each plan) the insurance pays after the deductible is met.

Copayment is the set amount the client pays (varies for each plan) then the insurance will pay the claim in full.  For example, if your plan has a $15 copay, the client pays the $15 and then the insurance covers the rest. Not all plans have a copayment