The entire process of claiming medical insurance can be surrounded by frustrations, pitfalls, and other elements that may lead to provider denials. One such major health insurance provider is Hartford, which offers the best group and individual health insurance plans.
The most common reasons for Hartford's denials must be understood by the healthcare provider and the patients so that they can work around the claim process easily and maximize the chances of success. The following comprehensive article outlines the top 5 reasons Hartford commonly denies insurance claims.
Some of the most frequent reasons some claims get denied by Hartford include incomplete or incorrect information on the insurance claim form regarding specific patient information, procedure code, or medical records.
In any of the instances noted above, the insurance company can deny the claim upon receipt. For example, a provider might omit writing the patient's full name, date of birth, or Hartford policy number.
In this regard, the insurance company cannot identify and process the claim accordingly. Another is an error in the CPT or ICD-10 coding used to describe the service performed.
Likewise, Hartford denial may occur if the treatment is deemed not to correspond with the filed claim as determined. This is one error that a health care provider should always avoid because they must ensure that every field in the Hartford insurance claim form is appropriately and thoroughly filled out before submission.
Another leading cause of Hartford's denials is that the insurance provider determines the medical service or treatment was not medically necessary. Hartford's insurance providers cover only procedures, tests, or therapies that are medically required or beneficial to diagnose or treat the patient's condition.
This is often a gray area as what constitutes "medical necessity" is not always well-defined. What Hartford considers an unnecessary service, the healthcare provider may think is an essential part of the patient's care.
The most common services to be denied based on a lack of medical necessity include:
Elective or cosmetic procedures
Off-label use of medications
Experimental or investigational treatments
Certain types of diagnostic testing
Healthcare providers can support the case for medical necessity by fully documenting patient symptoms, diagnoses, and courses of treatment in the record. This is further supported by documentation from clinical guidelines, peer-reviewed research, or the patient's history.
Hartford insurance policies have various exclusions and limitations, which are the most common reasons for denied claims from just about any insurer. What this means is that certain specific situations or treatments are not covered under this plan.
Some typical policy exclusions that lead to Hartford denials include, but are not limited to:
Routine vision or dental care
Durable medical equipment, in certain instances
Complementary and alternative therapies
Services received outside of the network of the plan
Hartford policies may also limit services in frequency, duration, or dollar amount. For example, the number of physical therapy visits per year may be limited, or the amount paid for a specific procedure may be capped.
Time is of the essence when filing insurance claims, and Hartford is no exception. It does have strict deadlines regarding the submission of claims, requests for appeals, and additional information.
For whichever of those steps that one fails to meet the deadline, the claim will be summarily denied. For example, Hartford generally requires that claims be submitted within 90 days of the service date.
If a provider misses this window, the claim will likely be denied, thus leaving the patient responsible for the full cost of care. Hartford also sets deadlines related to the filing of appeals or responses to requests for information, which significantly reduces the possibility of overturning an initial denial when these windows are missed.
To avoid such denials due to timing, healthcare providers would need to have some system by which times of claim submission and appeal are tracked. This can be accomplished by placing calendar reminders, using special billing software that tracks such events, or placing a staff member in charge of tracking the claims process.
Many Hartford insurance plans are designed to include prior authorization, or pre-authorization, for certain medical services and treatments. This is meant to ensure that the proposed care is medically necessary and aligns with the plan's coverage guidelines.
In the absence of this pre-authorization, even though the service would have been covered in nature, the plan can deny the claim altogether. The healthcare providers can make pre-authorizations through a call to Hartford, where supporting documents, including the patient's medical record and treatment plan, are sent.
The insurer will review all this information and make a decision. Providers must be very aware of what services require pre-authorization and initiate the approval process long before the treatment date.
Patients also need to be informed regarding the pre-authorization requirements of their plan and work with their providers to do just that. Without doing this, the patient may have large out-of-pocket costs.
Knowing the most frequent grounds for denial will go a long way in climbing the cumbersome world of Hartford insurance claims and will help improve reimbursement success.
Indeed, it is of the essence to send in complete and correct information, establish medical necessity, be aware of policy exclusions, and adhere to deadlines for pre-authorizations that minimize the risk of getting denials from Hartford and assure that the patients get the coverage they deserve.
Ultimately, claims processing at Hartford requires a collaboration of providers, patients, and the insurer itself to be competently managed.
