What does it mean when a claim is “denied”?

When a claim is described as “denied,” it indicates that the insurance company has determined that it will not provide payment for the services that have been billed. This situation can arise for various reasons, such as the service not being covered under the patient's policy, lack of medical necessity, incorrect coding, or a failure to meet the insurance company’s guidelines or requirements. Understanding what a denial means is crucial for healthcare providers and coding specialists, as it emphasizes the need to review and potentially appeal the denial based on the specific reasons provided by the insurer.

Other scenarios, such as claims being delayed for further investigation, approved but with adjustments, or pending review by a supervisor, do not reflect a denial but rather indicate different stages of the claims process. Each of these situations can involve communication and possible action required from the healthcare provider or coding staff, but they do not represent a refusal to pay the claim outright.