Reasons for Claims Denial

In addition to pended claims, claims processing may also result in the denial or rejection of claims. These claims may very well have come in as clean claims; however, some reason has been determined for the nonpayment of the claim. On average, 14 percent of claims received were denied for payment.
 

Almost half of all claim denials (48 percent) were due to the submission of a duplicate claim. Some plans indicated that though a claim may have been initially submitted electronically, there often is a paper claim received that unnecessarily follows up to confirm the submission.
 

A claim for a noncovered benefit, or for an individual who is no longer covered or whose policy has lapsed, each represented about 20 percent of rejected claims.

1. Non covered benefit
2. Eligibility issues
3. Coverage termination/
4. premium lapse
5. Duplicate claim
6. Other

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