Insurance is Unable to Process Your Claim

When you review an explanation of benefits from your insurance company, you may see instances where a claim hasn’t been processed or you notice the insurance company has not paid or adjusted the claim at all. Sometimes your medical claim is unable to be processed at the time of the submission, which is different than a “full” denial. In this case, the insurer will identify a reason why the claim cannot be processed, and include instructions on how to resubmit it.

Cited reasons may include:

    • Insurance information submitted with claim was incomplete


    • Lack of pre-certification or prior authorization, if required


    • Diagnosis and or procedure codes were missing or incorrect


    • Incomplete or inaccurate information on claims


    • Lack of medical documentation showing necessity of service


During the process of dealing with a resubmission or completion of claim paperwork, take careful notes on who you speak to and what action is being taken. Follow up through the entire process to ensure completion and that your claim is paid without undue delay.

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