Here are some common reasons for insurance denial during the TIP program along with what the next step should be.
Your current care is not deemed medically necessary or approved.
Work with your doctor through the plans appeals process to provide proof that your treatment is medically necessary.
The care is viewed as experimental or investigational.
Work with your doctor to illustrate that your current treatment is improving with data such as levels and recommended clinical guidelines.
The doctor you saw is out-of-network.
If the doctor you saw was out-of-network, you will be responsible for some or all costs, depending on your plan.
Medication or treatment is required but do not have a referral or prior authorization from your doctor.
Confirm if you needed a referral or prior authorization by checking your plan documents or by calling member services representative at your insurance company. Work with your doctor to submit the appropriate referral or prior authorization.
Your coverage has lapsed or you are no longer enrolled with the insurance company through which the claim was submitted.
Check with your doctor’s office to confirm they have submitted to the correct insurance company for you (sometimes they have outdated insurance information) and may need to resubmit.
Call the member services number at your insurance company to find out if or why your coverage has lapsed and provided any necessary information to confirm coverage if you are still enrolled and paying premiums.
What if I received a denial of my claim?
The first step is to find out why your claim was denied. Once you receive a Statement of Benefits to find out why your claim was denied.