Understanding Claim Denials and How HealthLock Can Help

To understand claim denials, and how HealthLock can help, follow the steps below:

What is a Denial?

A denial occurs when an insurance company refuses to pay for a medical service, procedure, or claim submitted by a provider or member. This can happen for various reasons, such as incomplete documentation, coverage limitations, or errors in coding.

Common Terms Used with Denials

• Appeal: A formal request to the insurance company to review and reconsider their decision to deny a claim.
• Overturn: The result of a successful appeal where the insurance company reverses its denial and approves the claim.

Types of Denials HealthLock Supports

• Post-Procedure Denials: These are denials issued after a service or procedure has been performed. Common reasons include incorrect coding, insufficient documentation, or deemed ineligible services.
• Claim Denials Related to Billing Errors: Denials due to discrepancies in charges, missing information, or unauthorized services.

Types of Denials HealthLock Does Not Support

• Pre-Procedure Denials: Denials issued before a service or procedure has been performed, often due to lack of prior authorization or coverage restrictions. These are outside the scope of HealthLock’s services.
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Steps to Address Denials with HealthLock

Step 1: Initiating the Process

1. Log in to Your HealthLock Member Portal.
2. On the Dashboard locate the "Received a claim denial?" module and click "Get help."
3. Provide as much detail about the denial as you can to speed the process.
   
   

Step 2: Providing Required Information

To process the denial effectively, members must provide the following:

• Correspondence or documentation received from the insurance company regarding the denial (i.e. a Denial Letter).
• A copy of the Explanation of Benefits (EOB) for the denied claim, if you have one.
• The billing statement from the provider, if you have one.
• Any other details about the denial that you feel are important.
  
  

Step 3: Submitting Additional Details (if requested)

If HealthLock’s team requires further documentation or clarification, you will be notified via the Member Portal. Please respond promptly to avoid delays.

Estimated Timeline for Resolution

The appeal and denial resolution process can take 30 to 90 days, depending on the insurance company’s policies and the complexity of the case. Delays can occur due to the following:

• Processing times by the insurance company.
• Additional documentation requests from the insurer.
• The nature and complexity of the denial.
  
  

Why Does the Process Take Time?

• Insurance Company Review: Insurers have specific timelines for reviewing appeals, often dictated by state or federal regulations.
• Documentation Evaluation: Ensuring all required documents meet the insurer’s criteria can involve multiple reviews.
• Follow-Ups: HealthLock’s team frequently follows up with providers and insurers to ensure your case progresses.