Health insurance denials are frustrating, stressful, and can often be financially devastating as well. While the state of California is one of the most consumer-protective states across the nation, Californians nonetheless receive denials from their health insurance company on a routine basis. These denials too often have little to do with the patient’s actual needs and much more to do with the health insurance company’s financial bottom line.
A health insurance denial is the first step in a battle with your insurance company to have your procedures, treatment, medication, medical devices, or other health care approved and paid for, and it is a process no patient wants to go through. Even if you eventually win, the fight for coverage can be aggravating, time-consuming, and deleterious to your emotional or mental health.
It is much easier to prevent insurance claim denials by taking the right steps beforehand. Unfortunately, there is no way to guarantee that an insurance company will approve your claim on its initial submission, and denials often stem from technical mistakes or missing paperwork. Denials are also the product of disputes over “medical necessity,” as well as whether the treatment is considered experimental or investigational.
The good news is that many health insurance denials are preventable when the right steps are taken early on in the process. Below are ten practical tips Californians can use to reduce the risk of a denied health insurance claim. Increasing your odds of approval for medical treatment can also involve speaking with a highly experienced health insurance denial lawyer at the Law Offices of Scott Glovsky.
Key Takeaways: Tips to Prevent Health Insurance Denials in California
- To prevent health insurance denials in California, confirm your plan details in writing before care: in-network status, referrals, and any prior authorization requirements for the procedure, imaging, or medication.
- Ask your doctor’s office to submit complete medical necessity documentation, including clinical notes, diagnostic results, and treatment history that matches what is being billed.
- Verify pharmacy and prescription rules ahead of time, including formulary coverage, step therapy requirements, quantity limits, and whether the drug needs prior authorization.
- Keep a paper trail. Save names, dates, reference numbers, and copies of all submissions so you can quickly fix coding errors, missing records, or insurer “proof” requests before a denial becomes final.
Verify Coverage Before Receiving Care and Always Refer to Your Plan Documents
Before you schedule a medical procedure, test, or specialist visit, it is extremely important that you confirm that the service is covered under your plan, the provider is in-network, and that no pre-authorization is required. Some treatments are not covered by your insurance, so before pursuing a procedure, you should check whether that treatment is covered under your plan. You should have received a handbook from your insurance provider outlining what is and is not covered. These plan documents are often called Evidence of Coverage and Summary of Benefits. If there are any questions, call the insurer to find out whether the treatment is covered before proceeding.
That said, never rely solely on verbal assurances from a provider’s office. Request written confirmation or document the date, time, and name of the insurance representative you spoke with. If you need to visit a specialist, you may need a referral. Check your plan or call your insurer to find out if this is the case. In many cases, a surgery or specific treatment may require pre-authorization under your plan. Whenever possible, contact your insurer in advance to find out whether your treatment needs pre-authorization.
Make Sure You Understand “Medical Necessity” Standards
It is very common for health insurance providers to deny a treatment by claiming it was not “medically necessary.” This can feel very confusing to you as a patient – after all, if your doctor believes it is a necessary service, then it is medically necessary, right? Unfortunately, this is not always the case. A 2023 study found that among those who are insured under the Affordable Care Act, at least six percent of all denials claimed “not medically necessary” as the reason for the denial. The definitions of medical necessity or medically necessary vary in insurance policies and Evidences of Coverage. So it is crucial to review your insurance policy to find the specific definition that applies to you.
To help avoid having your insurer claim the treatment is not medically necessary, ask your healthcare provider to:
- Clearly document your symptoms, the full diagnosis, and any prior treatments that were unsuccessful
- Explain thoroughly why the treatment is necessary for your health and is not optional
- Reference clinical guidelines and the “standard of care” whenever possible and appropriate
In theory, “medical necessity” is one standard for determining whether a drug, treatment, or service is covered. Insurers require drugs, treatments, and services to be medically necessary for diagnosing or treating a condition. They must also comply with accepted medical standards. Medical necessity may also mean treatment is expensive, and the insurer would rather avoid paying for it when possible. “Experimental” and “investigational” are also terms insurers use to avoid paying for medical treatment, though in some cases they are valid.
Definition of Medical Necessity
To meet the definition of medical necessity, generally the services must be clinically appropriate, rather than a convenience for the patient or provider. Some contracts provide that the service should not cost more than an alternative considered equally effective. An attestation from a physician that a service is medically necessary is an important consideration. A doctor or other healthcare provider may be asked to provide a “Letter of Medical Necessity” to the insurer as a part of a certification or “utilization review” process.
In some cases, a “precertification review” or preauthorization review may be conducted before treatment is provided, allowing the insurer to determine whether the requested treatment meets the plan’s medical-necessity requirements. This is generally accomplished by a review of the Letter of Medical Necessity, your medical records, and the plan’s coverage policies. A “retrospective review” may be conducted after treatment to determine whether the services were medically necessary.
You should be aware that even if a service is deemed medically necessary, it does not mean your insurer will cover all costs. You will likely still be responsible for copays, deductibles, and coinsurance.
Stay In-Network Whenever Possible
One of the most common triggers of insurance claim denials is out-of-network care. Even with California’s billing protections, an insurer may deny part of the claim, apply higher cost-sharing, or delay payment. If you are going into the hospital or clinic for a procedure, find out in advance if everyone involved in your care is part of your plan, including any anesthesiologists and/or specialists. If they are not included in your plan, they are considered out-of-network and may cause you to suffer additional charges or a claim denial.
Always Double-Check Billing and Coding Errors
Many health insurance claims are denied because a single digit is missing or incorrect, the claim lists outdated insurance information, or a diagnostic code does not match the procedure code. Inaccurate billing codes are another common source of denied claims. A patient may not know their specific diagnostic codes since they are very specific, but if the doctor’s office makes a coding error, the claim may be denied. If concerned, call your doctor’s office and ask a claims representative to double-check all coding.
Since so many treatments are denied due to a minor mistake, before submitting your claim form, make sure every field is filled in and that the information is correct. Incorrect or missing information on a claim form, such as the wrong Social Security number, can be a major trigger for denials.—. Knowing your insurance plan can help avoid insurance claim denials.
Make Sure You Have Copies of All Your Medical Records
While it can seem tedious and unnecessary, you should always maintain your own medical record file. In this file, you can include test results, doctor’s notes, referrals and authorizations, correspondence, and billing records. Having your own file of medical records can provide the essential, objective evidence necessary to prove medical care is required, as well as to fight insurer arguments that injuries are minor or pre-existing. Medical records link your injuries directly to an incident, clearly establishing that the treatment was medically necessary.
Having your own set of medical records allows you to find and fix any omissions or errors much more quickly. If you file an appeal for a claim denial, an organized file of medical records enables you to quickly gather the “additional evidence” required to support that appeal. Finally, having your own set of medical records ensures you are not surprised when the insurer raises an issue, and can directly challenge any discrepancies.
Keep a Close Watch on Authorization and Referral Deadlines
California insurers strictly enforce pre-authorization rules and the associated deadlines. Medically necessary care can be denied when the authorization was not submitted in a timely manner, the referral expired, or the service exceeded approved limits. It is important to always confirm approval before treatment, not after, whenever possible.
Make Sure You Know California’s Timely Filing Rules
Insurance plans impose deadlines for submitting claims—sometimes potentially as short as 90 days. If a provider misses the deadline, the insurer may deny payment entirely. It is important that you are aware of these timeframes to ensure the claim is filed by the deadline. Follow up with your medical providers to ensure claims are submitted on time, particularly after an emergency or complex care.
For emergency services, the authorization request should be submitted by the close of the next business day following the service date, when possible. If a denial occurs due to a lack of authorization, try to obtain a “retro authorization” or appeal the claim. Generally, claims should be filed promptly.
Read Your Explanation of Benefits (EOB) Carefully
Think of your EOB as a roadmap. Review it closely for partial denials, coding issues, or claim adjustment reasons. Under California law, the EOB must identify the denied claim, the specific services being denied, and the factual or legal basis for the denial. The Explanation of Benefits is the primary document used to initiate the internal appeal process. In most cases, the internal appeal must be filed within 180 days of receipt of the denial.
The EOB can help you catch mistakes such as billing errors, incorrect coding, and services that were wrongfully denied, and it outlines what the provider billed, what the insurer allowed, and what you are responsible for paying. Carefully review the “remark codes,” which explain the specific reason the claim was denied. Check the EOB against your provider’s bill for accuracy. The sooner you identify a problem, the more likely you are to be able to prevent the denial from becoming final.
Once You Receive a Denial, Act Quickly
California law allows consumers to appeal a claim denial, but there are strict time deadlines that can permanently bar your claim if missed. If you fail to appeal in a timely manner, you could be responsible for the full cost of the denied treatment. By promptly initiating the appeal process, you also ensure that essential medical care is not indefinitely delayed.
Quickly fighting a health insurance denial can also prevent the insurer from establishing a precedent, making it harder for them to deny similar future claims. When you initiate the appeal process with an experienced attorney, immediate pressure is placed on the insurance company, often resulting in a reversal of the denial.
Consider Using California’s Independent Medical Review (IMR)
In California, you can request an Independent Medical Review through the California Department of Insurance in some instances. If you request an IMR, your claim denial will be reviewed by independent physicians, is binding on the insurer, and can overturn wrongful denials. An IMR is a state-mandated, non-judicial process used to resolve disputes when a health plan denies, delays, or modifies services based on:
- A treatment being denied as “not medically necessary.”
- A service being deemed experimental or investigational.
- An emergency or urgent service denial
- A failed internal appeal process or an internal appeal that has been pending for too long.
The IMR process is generally fast, with decisions issued within 30 days, or even faster for urgent cases. IMRs are provided at no cost to California consumers. But sometimes seeking an IMR is not wise because if the IMR result sides with the health insurance company it can greatly undermine any civil legal remedies that you may have.
When Should You Contact a California Health Insurance Claim Denial Attorney?
Any time a claim is denied, you may consider contacting a California health insurance denial attorney from the Law Offices of Scott Glovsky. This is especially important if you have had multiple appeals denied, your insurer is ignoring deadlines, a denial involves high costs or life-saving care, or coverage was retroactively rescinded. Attorney Glovsky can potentially identify violations of California insurance law, forcing the insurer to comply. Receiving an insurance denial can be a traumatic experience—not to mention an expensive one. In order to ensure your claim has the best chance possible of being accepted, follow the aforementioned tips for preventing your claim from being denied and contact a local health insurance lawyer if you have any questions or concerns.
FAQ: Tips to Prevent Health Insurance Denials in California
What is the best first step to prevent health insurance denials in California?
Start by confirming coverage in writing before treatment: the exact service being requested, whether your provider is in-network, and whether prior authorization, referrals, or medical necessity documentation will be required.
How can I verify whether a doctor, facility, or lab is in-network?
Check your insurer’s provider directory, then call the insurer to confirm network status for the specific physician and facility. Ask for a reference number and keep a copy or screenshot of the confirmation.
When do I need prior authorization to avoid a claim denial?
Prior authorization is commonly required for advanced imaging, specialty procedures, surgeries, hospital admissions, durable medical equipment, and many high-cost prescriptions. Confirm requirements before the service is scheduled.
What should my doctor include to support medical necessity?
Strong documentation typically includes diagnosis details, symptoms, prior treatments tried and failed, objective test results, and a clear explanation of why the requested treatment is appropriate for your condition.
How do I prevent denials caused by billing or coding errors?
Ask the provider’s billing office to confirm the diagnosis code matches the procedure and that required modifiers are included. Request an itemized estimate and keep copies of orders, referrals, and clinical notes that support what is billed.
How can I avoid prescription and pharmacy-related health insurance denials?
Confirm the drug is on your plan’s formulary, check for step therapy or quantity limits, and verify whether prior authorization is required. If a specialty pharmacy is required, confirm which one your plan uses.
What information should I keep to prevent delays and repeat denials?
Keep a file with the insurer’s reference numbers, dates and names of representatives, copies of prior authorization approvals, letters, faxes, portal confirmations, and any “additional information” requests and responses.
What are warning signs that my claim might be denied?
Red flags include repeated requests for the same records, vague insurer explanations, sudden network disputes, “pending” status that lasts too long, or the provider saying they never received an authorization decision.
If I’m going to the hospital, what should I do beforehand to prevent a denial?
Confirm the admitting facility and treating doctors are in-network, ask whether the admission requires prior authorization, and request written confirmation of coverage for the planned procedure, anesthesia, labs, imaging, and post-care services.
When should I contact a California health insurance denial attorney about prevention or a pending denial?
Consider help if your insurer is delaying approvals, repeatedly requesting documentation, disputing medical necessity, or threatening non-coverage for expensive care. The Law Offices of Scott Glovsky serves clients across California from 343 Harvard Ave N, Claremont, CA 91711.