More about claims: What to know when a charge is denied

Finding out that one of your healthcare services was denied can be stressful and confusing. You may worry about the cost or wonder if there’s anything you can do.

A denial doesn’t always mean that you’ll have to pay for the service. Usually, there are clear next steps — and the Moda Health Customer Service team is here to help.

What happens when a service or charge is denied

It starts with a claim, which is a request for payment that your provider sends to your health plan after you receive care. It includes the services you received and the amount the provider is charging for those services. When your health plan denies a charge, it means the plan did not approve payment for that service — at least not yet.

Denials can happen for several reasons, including:

• A billing or coding error from the provider
• The service is not covered under your plan
• Your coverage wasn’t active when you got the service (if your coverage has ended or you haven’t paid your premium)
• Your provider is out of network and the service was not urgent or emergent
• Your provider needs to send more medical information

If you want to better understand how we decide who is responsible for paying a charge, there are four steps.

Step 1: Read your Explanation of Benefits (EOB)

Once your claim is processed, we’ll send you an Explanation of Benefits (EOB). On the right, you’ll see the Member Responsibility section. It shows what you owe for the services you received and whether it falls under copay, deductible or coinsurance. If you’d like to learn more about how to read your EOB, check out this handy guide.

• If the EOB shows that a service was denied, look for the reason code or explanation.
• If you see a denied service, but you don’t see an amount due in the Member Responsibility section, you don’t need to do anything. Moda Health will be working with your provider to take care of the denial, and you won’t be responsible for the charge.
• If you do see an amount due for the denied service under Member Responsibility, you’re unsure why your claim was denied or you are being billed by your provider for more than your Member Responsibility, you can contact Moda Health Customer Service to learn more and discuss next steps.

Step 2: Contact Moda Health

The Customer Service number on the back of your ID card is the best place to start. Let them know that you’ve seen a denial on your EOB and you want to understand why. You don’t have to figure this out alone. We’ll walk you through the details in plain language and help you:

• Understand the exact reason for the denial
• Learn if more information is needed
• Decide if you need to reach out to your provider
• Find out if the claim can be reviewed again

Step 3: Know your right to appeal

If, after you’ve discussed your options with us, you believe the denied charge should be covered, you have the right to appeal the decision. An appeal is a formal request asking your health plan to review the claim again. You can learn more about your right to appeal in your Member Handbook, which is available on your Member Dashboard. Your EOB also includes a short explanation of your right to appeal.

Step 4: Submit your appeal

Appeals are most successful when more information is provided. When you file an appeal, it helps to include:

• Medical records or notes from your provider
• A letter from your provider explaining why the care was needed
• Test results or other documentation that supports your case

Follow the steps listed in your denial letter or your Member Handbook and keep copies of everything. It’s a good idea to follow up after you’ve submitted your appeal to confirm that we’ve received your appeal and ask about when you can expect to hear back.