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10 Common Reasons Health Insurance Claims Get Denied

ByNisar Ali

Health insurance can be confusing, and it gets even more stressful when your claim gets denied, especially when you need coverage the most. Don’t worry, you’re not alone. In fact, about 60% of medical group leaders reported that denied claims increased in 2024 compared to 2023.

In this article, I’ll walk you through the most common reasons health insurance claims get denied, share the top health insurance claim denial reasons, and offer simple tips to prevent denied claims. By understanding these reasons, you can save time, money, and frustration, and get your claims approved faster.

Reasons Health Insurance Claims Get Denied

Insurance claims can be denied for many reasons. Sometimes it’s because of new rules or coding changes, and other times it’s because of simple mistakes on forms. Knowing what usually causes denials helps you avoid common pitfalls.

1. Treatment Not Seen as Necessary

Insurers may deny a claim if they don’t believe the treatment was medically necessary. They usually want a clear explanation from your doctor about why a procedure, test, or treatment is important.

Tip: Make sure your doctor clearly documents the medical reason in their notes. A well-documented claim has a higher chance of approval.

2. Your Plan Doesn’t Cover It

Sometimes the service you receive isn’t included in your insurance plan. Certain procedures, treatments, or tests may be excluded or limited.

Tip: Ask your provider to verify your insurance coverage before receiving care. This can prevent unpleasant surprises later.

3. Wrong or Missing Information

Even small errors, like a misspelled name, wrong policy number, or missing codes—can cause your claim to be denied.

Tip: Double-check all information on your claim forms and keep a copy for yourself. Accuracy matters!

4. Pre-Existing Conditions

Thanks to the Affordable Care Act, insurers can’t deny claims just because of pre-existing conditions. However, some plans may still have waiting periods or limits, which can lead to denials if you claim too early.

Tip: Read your plan carefully so you know what’s covered and when you can submit a claim.

5. Using an Out-of-Network Provider

Going to a doctor or facility that’s not in your network can lead to denials or higher out-of-pocket costs.

Tip: Always check if your provider is in-network before scheduling an appointment. Consider switching to an in-network provider if needed.

6. No Prior Authorization

Some procedures, tests, or medications need approval from your insurer before you get them. Skipping this step can result in a denied claim.

Tip: Ask your doctor or insurer if prior authorization is required before starting treatment. This simple step can prevent delays.

7. Policy Exclusions

Every insurance plan has certain things it won’t cover, called exclusions. If your claim falls under one of these, it will be denied.

Tip: Familiarize yourself with your plan’s exclusions. Knowing what’s not covered helps you plan your care and avoid surprises.

8. Exceeding Your Coverage Limits

Many plans limit the number of treatments or visits they cover. For example, your plan might cover 20 physical therapy sessions per year. Extra sessions beyond that may not be covered.

Tip: Check your plan’s coverage limits before scheduling additional treatments to avoid denied claims.

9. Filing Late

Insurance companies have strict deadlines for submitting claims. Filing late can lead to denial, even if your claim is valid.

Tip: Submit your claims as soon as possible after receiving care. Timely filing is one of the easiest ways to prevent denials.

10. Billing Mistakes

Sometimes claims are denied because of simple billing errors, like duplicate charges or incorrect procedure codes.

Tip: Compare your bills with your Explanation of Benefits (EOB) to catch errors early. Fixing mistakes quickly can save a lot of trouble.

What To Do If Your Claim Is Denied

Getting a claim denied can feel overwhelming, but understanding the reasons above can help you stay prepared. If your claim is denied:

  • Read the explanation carefully.
  • Check for errors or missing information.
  • Don’t hesitate to appeal the decision if needed.
Reasons Health Insurance Claims Get Denied

At CureIntent, we help patients and practices navigate denied claims, fix errors, and get the benefits they deserve. We guide you step by step so you don’t have to stress about the process alone.

Reach out today and let us make handling denied claims simple and stress-free.

Book a Demo

Frequently Asked Questions?

There are many reasons claims get denied. Common ones include the treatment not being medically necessary, using an out-of-network provider, missing prior authorization, billing errors, or coverage exclusions. Always check the Explanation of Benefits (EOB) for the exact reason.

Yes! You have the right to appeal a denied claim. Start by reviewing the denial letter and EOB, gather any supporting documents, and submit an appeal to your insurer. Getting help from a professional, like CureIntent, can increase your chances of success.

Insurance companies have strict deadlines. Claims usually need to be filed soon after receiving treatment, and appeals have their own time limits. Check your insurance policy for exact timelines to avoid missing the deadline.

Yes! You have the right to appeal a denied claim. Start by reviewing the denial letter and EOB, gather any supporting documents, and submit an appeal to your insurer. Getting help from a professional, like CureIntent, can increase your chances of success.

Compare your bill with the Explanation of Benefits (EOB) to identify mistakes like duplicate charges or incorrect codes. Contact your provider or insurer to correct any errors and resubmit the claim.

Professional help can make the process easier. At CureIntent, we assist patients and practices in handling denied claims, correcting errors, and ensuring you get the benefits you’re entitled to.

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