"Claim denied." Two words that feel final — but usually aren't. A large share of denied health-insurance claims are overturned on appeal. Here's how to read the letter and push back.
1. Find the denial reason
Every denial letter (and your EOB) states why the claim was denied, often as a short code or phrase. The reason determines your fix, so find it first. Common ones:
- Needs prior authorization — the service required pre-approval that wasn't obtained.
- Out of network — the provider isn't in your plan's network.
- Not medically necessary — the insurer decided the service wasn't required.
- Coding / billing error — the claim was submitted with a wrong or missing code.
- Missing information — the insurer wanted records the provider didn't send.
2. Check for the easy fixes first
Many denials are clerical. A coding error or missing-information denial is often fixed by a quick call to your provider's billing office asking them to correct and resubmit the claim — no formal appeal needed.
3. Know your right to appeal
You have a legal right to appeal. There are two levels: an internal appeal (you ask the insurer to reconsider) and, if that fails, an external review (an independent third party decides). You typically have 180 days from the denial to file the internal appeal — check your letter for the exact deadline.
4. Write the appeal
Keep it factual: reference the claim number, state why the service was necessary, and attach supporting documents — a letter from your doctor ("letter of medical necessity") is powerful for "not medically necessary" denials. Send it in writing and keep copies of everything.
5. Don't pay the full bill while appealing
While a claim is under appeal, you generally shouldn't pay the full billed amount. Tell the provider the claim is being appealed so the bill isn't sent to collections in the meantime.
The bottom line
A denial is the insurer's first answer, not the last word. Find the reason, fix the simple ones with a phone call, and appeal the rest — the odds are better than most people think.
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