Denial
A denial refers to the refusal of an insurance company or payer to reimburse a healthcare provider for a medical service or procedure that has been billed. Denials can occur for various reasons, such as incomplete or inaccurate information on the claim, lack of pre-authorization, exceeded coverage limits, or non-covered services. When a claim is denied, the healthcare provider or billing staff must investigate the reason for the denial and take appropriate action to address it.
This may involve correcting errors on the claim, providing additional documentation or justification, or filing an appeal with the insurance company. Effective denial management is crucial for healthcare organizations to minimize financial losses, optimize revenue cycle management, and ensure timely reimbursement for services provided to patients.