Insurance Denied Your Claim? Here's What to Do Next

You followed the rules. You went to an in-network doctor, got the referral, and had the procedure your physician recommended. Then the letter arrived: claim denied. It's frustrating, it's confusing, and it can feel deeply unfair. But here's the thing most insurance companies won't tell you: a denial is not the end of the road. It's the beginning of a process — and one you can win.

Why Claims Get Denied

Before you can fight a denial, it helps to understand why it happened. The most common reasons include:

• Prior authorization wasn't obtained. Some procedures require advance approval. If your provider didn't get it — or the paperwork was incomplete — the claim may be denied even though the care was medically necessary.
• The service was deemed "not medically necessary." This is one of the most common (and frustrating) reasons. The insurer's reviewer may disagree with your doctor's assessment, often based on limited information.
• Coding errors. A wrong diagnosis code or procedure code can trigger an automatic denial. These are surprisingly common and usually fixable.
• Out-of-network provider. Even if you didn't have a choice — like in an emergency — some plans will deny claims for out-of-network care.
• Timely filing. If the claim wasn't submitted within the insurer's deadline, it may be denied regardless of merit.

Step 1: Read Your Denial Letter Carefully

Your denial letter (sometimes called an Explanation of Benefits, or EOB) is required to tell you why the claim was denied and what your rights are. Look for:

• The specific reason for the denial
• The deadline to file an appeal (typically 30 to 180 days)
• Instructions for how to submit an appeal
• Contact information for the insurer's appeals department

If the language is confusing — and it often is — don't be afraid to call the insurance company and ask them to explain it in plain terms.

Step 2: Gather Your Documentation

A strong appeal is built on evidence. Collect everything that supports the medical necessity of the care you received:

• A letter from your doctor explaining why the treatment was necessary, including clinical notes and test results
• Medical records that document your condition and treatment history
• Published medical guidelines or peer-reviewed studies that support the treatment your doctor recommended
• A copy of your insurance policy — specifically the sections that cover the service in question

Step 3: Write a Clear, Factual Appeal Letter

Your appeal letter should be organized, professional, and focused on the facts. Include:

• Your name, policy number, and claim number
• A clear statement that you are appealing the denial
• The reason the claim was denied (as stated in the denial letter)
• Why you believe the denial was wrong, supported by your documentation
• A request for the claim to be reprocessed and paid

Keep emotion out of the letter — even though it's an emotional situation. Stick to medical facts and policy language. The goal is to make it as easy as possible for the reviewer to approve your appeal.

Step 4: Submit and Follow Up

Submit your appeal before the deadline, and keep copies of everything. Send it via certified mail or a trackable method so you have proof of delivery. Then follow up:

• Call the insurance company a week after submitting to confirm they received it
• Ask for a timeline — most insurers are required to respond within 30 to 60 days
• Document every call: the date, the representative's name, and what was said

Step 5: Know Your Right to an External Review

If your internal appeal is denied, you're not out of options. Under the Affordable Care Act, you have the right to an external review — where an independent third party reviews your case. This reviewer has no ties to your insurance company and can overturn their decision.

External reviews are free, and insurers are legally required to comply with the outcome. Many patients don't know this option exists, but it can be a powerful tool — especially when you have strong medical evidence on your side.

When to Bring in an Advocate

You have every right to handle an appeal on your own. But the process can be time-consuming and emotionally draining — especially when you're already dealing with a health issue. A patient advocate can take the burden off your shoulders. They know the system, they know the language, and they know how to build a case that gets results.

Whether you're facing your first denial or your third, you don't have to go through it alone.