Can An Insurer Reject A Claim For An Emergency Procedure Without Prior Approval?

In most cases, insurers cannot reject a claim for an emergency medical procedure simply because it was not pre-approved. Health insurance policies are typically required to cover emergency care, even if it was not authorized in advance. However, there are important exceptions and details that policyholders should be aware of.

Can an Insurer Reject a Claim for an Emergency Procedure Without Prior Approval?

1. Emergency Medical Care Is Generally Covered
   Under most health insurance plans, emergency medical services are covered, even if they were provided without prior authorization. This is in line with both federal regulations and state laws, which recognize that in emergency situations, seeking immediate care is crucial, and getting prior approval from an insurer may not be feasible or appropriate.
   • Federal Law: Under the Emergency Medical Treatment and Labor Act (EMTALA), hospitals are required to provide emergency medical treatment to all patients, regardless of their ability to pay or insurance status. This law ensures that patients are not turned away from emergency care based on their insurance provider’s pre-authorization requirements.
   • Health Insurance Portability and Accountability Act (HIPAA): HIPAA regulations and the Affordable Care Act (ACA) stipulate that emergency services must be covered by insurance without prior approval, whether or not the procedure was pre-authorized.
2. Definition of an Emergency
   Health insurance policies typically define what constitutes an emergency or emergency medical condition. These definitions usually include situations where:
   • A serious injury or acute illness occurs.
   • There is a risk of permanent damage to health or life.
   • Immediate medical attention is needed to avoid death or long-term impairment.
   If the procedure was deemed medically necessary in the context of an emergency, the insurer is generally obligated to cover the costs, even without prior approval. However, the insurer might require a post-service review to confirm that the treatment was indeed for an emergency and medically necessary.
3. What Happens After Emergency Care?
   After receiving emergency medical treatment, insurers often require the hospital or healthcare provider to submit documentation of the emergency event for review. If the insurer believes the situation did not constitute an emergency, they may attempt to deny or reduce the payment based on the specifics of the policy, even though they cannot reject the claim outright due to the lack of prior approval. Common post-treatment reviews include:
   • A review to determine if the care was truly emergency-related.
   • Checking whether the procedure was consistent with the policy’s coverage for emergency services.
   • Reviewing the medical necessity of the treatment.
4. Prior Authorization May Be Required for Non-Emergency Procedures
   For non-emergency medical services, insurers often require prior authorization. This means that procedures such as elective surgeries or non-urgent treatments often need to be approved by the insurer before they are performed. However, emergency procedures are treated differently and generally do not require prior authorization, as it would not be feasible to wait for approval in life-threatening situations.
5. State Regulations and Protections
   In addition to federal laws, individual states may have additional protections for consumers when it comes to emergency care. Some states have laws that require insurers to provide immediate coverage for emergency medical conditions without requiring prior approval. Even if an insurer initially denies a claim, these protections may allow the policyholder to appeal the decision or seek legal recourse.

What Should You Do If Your Emergency Claim Is Denied?

1. Review the Policy
   Start by reviewing your insurance policy to determine what is covered under emergency services. Ensure that the treatment you received qualifies as an emergency under the terms of your plan.
2. Verify the Medical Necessity
   If the insurer denies the claim, it’s important to check if the insurer's decision was based on an incorrect assumption about the medical necessity of the treatment. You can work with your healthcare provider to ensure that they submitted the appropriate documentation showing the treatment was necessary to address an emergency condition.
3. Appeal the Denial
   If your insurer rejects the claim based on lack of prior approval or any other reason, you can appeal the decision. Most insurers have a formal appeals process where you can submit additional documentation or argue that the treatment was indeed an emergency. Be sure to include:
   • Medical records and notes from your doctor detailing the urgency of the situation.
   • Bills or statements showing the cost of treatment.
   • Any other evidence proving that the care was needed immediately to preserve your health.
4. Contact State Insurance Department
   If your insurer refuses to cover the emergency procedure after an appeal, consider contacting your state’s insurance department or consumer protection agency. They may be able to help resolve the issue or provide guidance on whether the insurer is violating any state laws.
5. Seek Legal Advice
   In some cases, consulting an attorney who specializes in health insurance disputes or consumer protection law may be helpful. They can assist you with the appeals process, and if necessary, help you pursue legal action.

Example

Suppose you experience severe chest pain and are rushed to the emergency room, where doctors determine you need immediate surgery to treat a potentially life-threatening condition. After treatment, your insurer denies the claim, stating that prior approval was required.

• Step 1: Review your insurance policy’s emergency care provisions. You find that emergency services are covered regardless of prior authorization.
• Step 2: Request documentation from the hospital to confirm that the procedure was medically necessary and classified as an emergency.
• Step 3: Appeal the insurer’s denial with the documentation showing the urgency of the situation and the necessity of the treatment.
• Step 4: If the appeal is unsuccessful, contact your state insurance department to review your case and help resolve the dispute.

Conclusion

Generally, insurers cannot reject a claim for an emergency medical procedure solely because it lacked prior approval. Emergency medical care is typically covered under health insurance policies, even if it wasn’t pre-authorized. If an insurance provider does reject a claim, policyholders can appeal the decision and, if necessary, seek help from state regulators or legal counsel to ensure their rights are upheld.