What is a coverage denial?

A coverage denial is when a health insurance provider refuses to cover an insurance claim or a service. This type of denial usually happens when an individual has not received pre-authorization before seeking care or if the claim is considered outside the plan’s network or coverage areas. In California, the Department of Managed Health Care (DMHC) regulates health care insurance plans, and they have specific rules in place that may help with coverage denial. The first step if you experience a coverage denial in California is to contact the DMHC. The DMHC staff will review the claim rejection and document a resolution. Additionally, if your health plan does have a coverage denial you can appeal the decision by submitting a written appeal to your health plan. Each health plan has 40 days to review the appeal and make a decision. The appeal response will explain any additional information that you may need to submit or why your service or claim was denied. If you’re still not satisfied after the appeal decision, you may file a complaint with the DMHC. You must include the reason you are not satisfied with the appeal. A mediator from the DMHC will contact you and help you resolve any issues with the health plan. The mediator may also help you understand which steps you must take to obtain the services and treatment you need.

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