You’ve paid your premiums. You followed the rules. You expected your insurance to cover the care you needed.
Then you get the letter: “Claim Denied.”
It’s frustrating—but not the end of the road.
Denied claims happen all the time, and many are overturned when patients take the right steps. In this post, you’ll learn exactly what to do if your health insurance claim is denied, how to respond, and how to protect your rights as a patient.
🧾 Step 1: Review the Denial Letter and EOB
Start by reading:
- The denial notice from your insurance company
- Your Explanation of Benefits (EOB)
Look for:
- The reason for denial (usually with a code and brief explanation)
- The date of service and provider
- Your right to appeal and the deadline to do so
💡 Tip: Insurance companies are legally required to explain the reason for denial—but you may need to dig into the policy language.
🔍 Step 2: Understand the Reason for Denial
Common reasons for health insurance claim denials include:
- The service was not medically necessary
- The provider was out of network
- You didn’t get prior authorization
- Incorrect or missing billing codes
- The claim was submitted after the filing deadline
- Coverage was terminated or inactive
Knowing why your claim was denied will guide your next move.
📞 Step 3: Contact the Insurance Company
Call the number on the back of your insurance card. Ask:
- Can you clarify the denial?
- Was this a billing or coding error?
- Is there missing documentation?
- Can this be reprocessed without an appeal?
🧠 Keep notes: Who you spoke to, what was said, and the date/time.
Sometimes denials can be resolved without filing a formal appeal.
🩺 Step 4: Talk to Your Medical Provider’s Billing Department
Your provider’s office may:
- Spot billing errors
- Resubmit the claim with corrected codes
- Provide medical records or letters of medical necessity
- Help you draft an appeal if needed
🚨 Important: If your provider submitted the claim incorrectly, they can often fix it without involving you in a full appeal.
📝 Step 5: File a Formal Appeal (If Needed)
If the denial stands and you disagree, it’s time to file an appeal.
Follow your insurer’s instructions carefully. Include:
- A copy of the denial letter and EOB
- An appeal letter stating your argument
- Doctor’s support and relevant medical records
- Any proof of prior authorization or policy terms
Most insurers allow appeals within 180 days of denial.
⚖️ Step 6: Request an External Review
If your internal appeal is denied, you may qualify for an external review—an independent decision made by a third-party medical expert.
You’re legally entitled to an external review under:
- The Affordable Care Act
- State insurance laws
External review decisions are binding and usually issued within 30–45 days.
💼 Step 7: Escalate or File a Complaint
If you’ve exhausted appeals and still believe your claim was wrongly denied, consider:
- Filing a complaint with your state’s insurance department
- Contacting the U.S. Department of Labor (if you have employer-sponsored insurance)
- Consulting a healthcare attorney or billing advocate
🧠 Pro tip: Keep copies of all documents, letters, emails, and phone logs—this paper trail strengthens your case.
🧠 You May Wanna Check Out:
✅ Final Thoughts
A denied health insurance claim can be stressful—but it’s not the end of your case.
Stay calm. Review the denial. Collect your evidence. File a timely and well-supported appeal.
And remember: you have rights.
The more informed and proactive you are, the better your chances of turning a “no” into a “yes.”
