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.
In fact, denied health insurance claims happen all the time, and many patients overturn them by taking 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 Health Insurance Denial Letter and EOB
To get started, read:
- 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 must explain the reason for denial—but you may need to dig into the policy language.
Additionally, double-check your EOB against your actual treatment to ensure there are no unexpected charges.
Step 2: Understand the Reason for the Denied Health Insurance Claim
For example, common reasons for health insurance claim denials include:
- The service wasn’t deemed 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 had already been terminated
As a result, understanding the reason for denial will help guide your next move.
Step 3: Contact the Insurance Company About the Denied Claim
Next, 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.
In some cases, you can resolve denials without filing a formal appeal. Therefore, always make the call before assuming the worst.
Step 4: Talk to Your Medical Provider’s Billing Department
In many cases, your provider’s office can:
- 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. Additionally, they may offer documentation to support your case.
Furthermore, providers are often familiar with insurer appeal processes and can help you avoid common mistakes.
Step 5: File a Formal Health Insurance Appeal (If Needed)
If the denial still stands and you disagree, it’s time to file an appeal.
At this point, 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
Typically, insurers allow appeals within 180 days of denial. Moreover, submitting your appeal early gives you time to fix any additional issues.
In some situations, attaching a letter from your doctor explaining the medical necessity can significantly strengthen your appeal.
Step 6: Request an External Review of the Denied Health Insurance Claim
If your internal appeal is denied, you may qualify for an external review—an independent decision by a third-party medical expert.
Importantly, the Affordable Care Act and state laws guarantee your right to an external review.
As a result, external review decisions are legally binding and typically issued within 30–45 days. Therefore, don’t skip this step if your appeal fails.
Additionally, external reviewers evaluate the medical evidence and policy terms objectively.
You can learn more about external reviews from the U.S. Department of Health & Human Services.
Step 7: Escalate or File a Complaint with State Insurance Regulators
Finally, 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 (for employer-sponsored insurance)
- Consulting a healthcare attorney or billing advocate
Pro tip: Always keep copies of documents, letters, emails, and phone logs—this paper trail strengthens your case. In addition, it helps you track communication timelines.
If you’re unsure of your rights, visit your state’s insurance department website for more information.
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Final Thoughts on Denied Health Insurance Claims
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.
Ultimately, staying informed and proactive gives you the best chance of turning a “no” into a “yes.”
As always, the more prepared you are, the more confident you’ll feel navigating this process.
Frequently Asked Questions (FAQs)
Q: Why would a health insurance claim be denied?
A: Common reasons include missing prior authorization, incorrect billing codes, or out-of-network care.
Q: Can I appeal a denied insurance claim?
A: Yes. Most insurers allow appeals within 180 days. You’ll need a denial letter, EOB, and medical records.
Q: What if my appeal is denied?
A: You can request an external review or file a complaint with your state’s insurance department. Learn more at HealthCare.gov.
Need help with the appeals process? Explore more in our Medical Billing & Insurance Law section.
