Connecticut State Office of the Healthcare Advocate

NOTICE: The Office of the Healthcare Advocate is currently closed to public visitors as a protective measure for the safety of customers and staff. We will continue to provide services by email and telephone. The Office of the Healthcare Advocate may be contacted by utilizing our on-line services on our website, by calling our main number at 1-866-466-4446 or by emailing us at healthcare.advocate@ct.gov


You've been denied, so what now?


If you've been denied coverage for a service, treatment, medication, etc by your insurance company, it can be a confusing and daunting process.  Don't worry, you may have options. 


An important step in understanding what these options are is understanding what has actually been denied and why.  If your insurer has determined that they cannot approve coverage of some service or treatment, there are many possible reasons why the request has been denied.  You should receive a document from your insurer called an Explanation of Benefits.  This is a document that insurers are required to provide you by law that explains how each claim or request for service has been evaluated.  A sample is shown below:



mn sample

As you'll see in the highlighted text, the insurer identifies the reason why the claim or service was denied.  There can be many reasons for this, including, but not limited to:


   - Insufficient information about the requested service


   - The requested service is not a covered benefit under your plan


   - While the requested service is covered under your plan, you did not meet the insurer's "medical necessity" standard (this is common, and can stem from many causes). 


While the insurer in the example above denied the claim, it did so because it received insufficient clinical information about the requested service to make a determination whether the service met the clinical criteria for being medically necessary.


For a denial like this, the first step is simple - make sure that your provider sent the medical records about the service to the insurance company.  While a letter from your provider is helpful, the insurer will typically need to see the medical records, including any related labs, radiology and doctor's notes, in order to approve coverage.  If the provider is in network, and failed to do so, the claim for payment may ultimately be denied. 


If so, the insurer pays nothing for the service, but it is important to understand that you may not be responsible to pay the provider for the service.   As an in-network provider, these providers have agreed to do certain things, like submitting a claim for payment to the insurance company in a timely manner, in the proper format, and with the necessary documentation.  If the provider fails to do so, they may be non-compliant with that agreement, and the insurance company does not need to pay the claim.  These agreements typically have a provision that states that a provider cannot hold you responsible when they failed to follow the protocol.  Out-of-network providers are not subject to these same requirements, and have no obligation to send anything to the insurer to help your claim be paid, unless they provided you with information stating that they would do so.


As you can see from this simple example, it can be quite a challenge to know what your rights and obligations are when your insurance has denied a claim.  In the following section, we will examine some of the most common reasons claims are denied, and provide some suggestions about how to understand what needs to be done and what your obligations may be.






Appeals continued...