Health Insurance denials can happen for a number of reasons.
A simple cause can be a billing error from the provider's office.
If the claim is submitted using the wrong treatment or diagnostic code, the claim can be denied.
More serious reasons can involve treatments considered "experimental" or "pre-existing".
Both of these reasons can be appealed if you feel the insurance company's decision is wrong.
If your healthcare claim is denied, you have the right to appeal.
Health Insurance carriers are required to provide an appeals process.
Typically there are a few levels of appeal, each moving more 'independent' by involving impartial medical professionals.
Washington State also provides the Patient's Bill of Rights which provides an independent third-party review of your appeal, if the standard appeals process is unsuccessful.
Washington Health Insurance Agency provides assistance through the appeals process, by walking their health insurance clients through the steps, carefully tracking the appeal deadlines, recommending the best supporting documents, and even participating in the appeal discussion board via conference call on behalf of their clients.
The most important thing to remember is that if you feel the denial is wrong, you have to appeal.
Many people just assume there is nothing they can do.
Often the claim denial can be reversed with a simple phone call, and the appeal process can be avoided altogether.
Reason Codes are found on the Explanation of Benefits statement from the insurance company that can provide useful information in determining the reason for a claim being denied.
It's up to you to check your statements carefully.