What Is Denial?
An insurer's decision to refuse payment for a claim, typically based on exclusions, lack of medical necessity, policy limits, or violation of policy terms. Insureds have the right to appeal denials.
Denial across 2 exams
Denial appears on the following exams. Each defines it in the context candidates are tested on:
- Health Insurance
- An insurer's decision to refuse payment for a claim, typically based on exclusions, lack of medical necessity, policy limits, or violation of policy terms. Insureds have the right to appeal denials.
- CBCS (NHA)
- A payer's decision to refuse payment for all or part of a claim, either because of a coding error, lack of medical necessity, missing documentation, or coverage limitations. Denials must be addressed through appeals or provider education.