What Is a Technical Denial in Healthcare?

A technical denial in healthcare refers to a health insurance claim denial stemming from administrative or procedural errors in the submission process. These denials are not a judgment on the medical appropriateness of the services received. Technical denials are frequently rectifiable, meaning the claim can be corrected and resubmitted for reconsideration.

Common Causes of Technical Denials

Numerous administrative and clerical errors can lead to a technical denial. One frequent issue involves incorrect patient information, such as a misspelled name, an inaccurate date of birth, or an outdated insurance identification number. Claims can also be denied if the patient’s insurance coverage was expired or invalid on the date the service was provided.

Another common cause is the failure to obtain pre-authorization or pre-certification when required by the insurance plan for specific services or procedures. Duplicate billing, or incorrect coding like wrong CPT or ICD-10 codes, also frequently result in technical denials. Claims submitted after the insurance company’s timely filing limit, typically within 12 months for Medicare, are also denied. Additionally, services provided by an out-of-network provider without proper notification or authorization may lead to a technical denial.

How Technical Denials Differ from Medical Necessity Denials

Technical denials and medical necessity denials are distinct categories of health insurance claim rejections. A technical denial focuses on administrative or procedural shortcomings in the claim submission. This means the service may have been medically appropriate, but the claim failed due to issues like missing information or incorrect codes.

In contrast, a medical necessity denial occurs when the insurer determines that the healthcare service provided was not medically necessary for the patient’s condition, based on their established clinical guidelines. Such denials question the clinical justification for the care.

While a technical denial can often be resolved by correcting administrative errors, a medical necessity denial typically requires a more extensive appeal process, often involving clinical documentation to justify the medical need.

Steps to Resolve a Technical Denial

Resolving a technical denial involves a systematic approach, beginning with a thorough review of the denial notification. Examine the denial letter from your insurance company, as it specifies the reason for the denial, your appeal rights, and submission deadlines. Gather all pertinent documents, including insurance policy details, pre-authorization confirmations, and relevant medical records or doctor’s notes.

Next, contact your healthcare provider’s billing department to understand their process for addressing denials and to confirm the information they submitted. Simultaneously, reach out to your insurance company for clarification on the denial code. Document the date, time, and name of the person you speak with during all communications, along with a summary of the conversation.

If an administrative error is identified, such as incorrect patient information or coding, ask your provider to correct and resubmit the claim. For other technical issues, you will likely need to initiate an appeal with your insurance company. Prepare an appeal letter that clearly states your name, policy number, claim number, and the dates of service. Explain why you believe the denial was incorrect, referencing specific details and attaching all supporting documentation.

Most insurance companies require an internal appeal within 180 days of receiving the denial notice. Submit your appeal and all supporting documents within the specified timeframe, keeping copies for your records, and follow up consistently on the status of your appeal.