What should patients do if they do not understand why a claim was denied?

• A. Encourage them to call the insurance company and question the rejections.
• B. Ignore the denial and assume it's resolved.
• C. Submit a new claim without addressing the denial.
• D. Seek legal action.

Answer: (D)

When a claim is denied, the essential step is to understand and challenge the decision through the payer’s process. Start by obtaining the denial notice and the Explanation of Benefits to see the exact reason for the denial. Common causes include missing or incorrect information, lack of medical necessity, coding errors, or coverage limitations. Reach out to the insurer to get a clear explanation and to confirm what is needed to overturn the denial.

The most effective path is to file a formal appeal with the insurer, supplying any required documentation such as medical records, physician notes, test results, corrected codes, and a concise statement of medical necessity. The provider can help prepare and resubmit the claim if needed. If the initial appeal is denied, pursue the next levels of appeal or external review as permitted by state law, adhering to all deadlines. Legal action is not the usual first option and can be costly and time-consuming; typically, denials are resolved through the payer’s internal and external review processes.