Key points
- A denial is a decision not to pay or approve. You can appeal it.
- A rejection usually means the claim was incomplete or wrong and was not decided. Someone fixes it and sends it again.
- Your share of the cost is the deductible, copayment or coinsurance. It is not a denial, though it may feel like one.
- Which one you have decides who acts first.
A denial is a decision. A rejection is usually a mistake or a missing piece that stopped the claim from being decided. Your share of the cost is neither: the plan processed the claim as it should and the rest is yours. The three can look alike on a statement, but you answer each one differently.
What this means
- Denied. The plan decided not to pay or approve all or part of something. Private plan rules call this an adverse benefit determination, which includes a denial, a reduction, an ending of a benefit, or a failure to pay in whole or in part. It comes with appeal rights.
- Rejected. The claim could not be processed, often because of a wrong member number, a missing code, a duplicate or a missing form. “Rejected” is how plans and billing offices describe it; it is not a term the federal rules use. The plan has not decided whether to pay. If the claim is incomplete, a private group plan has to say what is missing, and for a claim that is not urgent it has to give you at least 45 days to supply the information.
- Your share. The plan applied your deductible (what you pay before it pays), copayment (a set fee) or coinsurance (a percentage). Your statement may show these under “patient responsibility”. Nothing was refused.
- Excluded. A fourth case. The plan document says the service is never covered. This is a denial, but it usually turns on what your plan document says, not on medical need.
| What you see | Most likely | Who acts first |
|---|---|---|
| “Claim denied”, “not medically necessary”, “not covered”, with appeal instructions | Denial | You, often with your doctor |
| “Rejected”, “resubmit”, “missing information”, “invalid member number” | Rejection | Your provider, or you if the information is yours |
| “Patient responsibility”, “deductible applied”, “copay” | Your share | You check the math; the plan or provider fixes mistakes |
| “Excluded”, “not a benefit of your plan” | Denial by exclusion | You check the plan document and decide whether to challenge |
What to do
- Find the document. An Explanation of Benefits (EOB), a denial letter, a bill or a pharmacy message. Only the first two come from the plan. Start with how to read an EOB.
- Look for appeal language. A denial notice tells you how and when to appeal. A rejection usually does not. If you cannot tell, ask the plan: “Did you deny this claim, or reject it without deciding?”
- Ask for the answer in writing. If you are told “denied” by phone, use the request for a denial in writing.
- For a rejection, ask your provider’s billing office to correct and resend the claim, and ask the plan what exactly was missing. Ask for a date by which it will be done.
- For your share, check the math. Compare the amount with your plan’s deductible and copayment, and ask for reprocessing if it looks wrong. The script to ask for reprocessing has the words.
- For a denial, note the deadline and go to the first 48 hours.
- Put any bill on hold. Use the bill hold request while the question is open.
What the plan or provider may say, and what to say back
“Your claim was rejected. Please resubmit.” Ask: “Was a decision made on the claim? What exactly was missing?” Ask your provider to resend it, and note the date. Watch the deadline for filing claims; see filed too late.
“This is your responsibility.” Ask: “Which part is deductible, which is copayment and which is coinsurance, and where is that in my plan documents?”
“That service is not covered.” Ask: “Which plan provision says so?” If the real reason is medical judgment, an appeal may still make sense.
The rule
An adverse benefit determination is a denial, reduction or termination of a benefit, or a failure to pay in whole or in part, including a finding that care is experimental, investigational or not medically necessary. Source: Code of Federal Regulations (CFR) Title 29, section 2560.503-1(m)(4), the federal claims regulation.
Watch for
- One claim can be all three. One line denied, one rejected, one your share.
- A rejected claim can turn into a denial. If it is not fixed and resubmitted in time, the plan may deny it as filed too late. Chase the fix.
- The word “denied” on a pharmacy screen may be a rejection, a prior authorization requirement or a plan rule. See the kinds of no.
- A bill is not a decision. A provider bill does not tell you what the plan decided. See a bill is not an EOB.
- Out-of-pocket limits. If you think you have paid more than your plan’s yearly limit, ask the plan to show your running total before paying more.
What next
- Learn to tell types of refusal apart: the kinds of no.
- Decide who acts first: whose job is it to fix this.
- Fix a billing mistake: coding and billing errors.
- Go to the topic page, work out whether it is really a denial.