Your Health Insurance Claim Was Denied…Now What?

You’ve been to the doctor, followed the rules, and expected your insurance to take care of the bill. Then, you get that letter (or worse, a bill) saying your health insurance claim was denied. It’s confusing, frustrating, and a little scary—especially if the amount is more than you can afford to pay out of pocket. But don’t panic. A denied claim doesn’t mean the fight is over. With a few smart steps, you may be able to get that claim approved and avoid paying more than you should. Here’s what to do next.

What Does It Mean When a Claim Is Denied?

When a health insurance claim is denied, it means your insurance company has decided they won’t pay for a medical service you received. That decision could be for the entire bill or just part of it.

Claims can be denied for all kinds of reasons, including:

• Incorrect or incomplete paperwork
• The procedure or service wasn’t covered under your plan
• You didn’t get pre-authorization or a referral
• The provider was out-of-network
• The insurer thinks the service wasn’t medically necessary
• You’ve hit your plan’s limits for that type of care

Sometimes the denial is legitimate, but many times it’s due to a simple error or miscommunication that can be corrected.

Step 1: Don’t Ignore It

The worst thing you can do is toss the denial letter in a drawer and hope it goes away. Health care bills don’t magically disappear—and neither do appeals deadlines. Most insurance companies give you a limited time (often 90–180 days) to appeal a denied claim, so time matters.

Take a deep breath and get ready to dig into some paperwork. You’ve got options.

Step 2: Read the Explanation of Benefits (EOB)

An Explanation of Benefits isn’t a bill—it’s a breakdown of how your insurance processed your claim. It shows:

• What service you received
• What your provider charged
• What the insurer covered
• What you owe
• The reason for denial (usually a code with a short explanation)

This is your starting point. Match the EOB to any medical bills you’ve received, and note the exact reason your claim was denied. That info will guide your next steps.

Step 3: Call Your Insurance Provider

Before you write an angry letter or start an appeal, call your insurance company. Sometimes the denial is the result of a coding error, a missing piece of information, or a paperwork mix-up that can be fixed quickly over the phone.

When you call, have your:

• Insurance card
• EOB or denial letter
• Provider’s information
• Date and type of service

Ask the rep to explain the denial in plain English. Take notes—including the rep’s name and the date of the call.

Step 4: Contact Your Health Care Provider’s Office

Your doctor’s office or hospital billing department may be able to help resolve the issue, especially if the denial was due to a coding or paperwork error. In some cases, they can resubmit the claim with the correct information or provide additional documentation that supports why the service was necessary.

Be polite but persistent. Their help can speed up the process and improve your chances of success.

Step 5: Gather Documentation for an Appeal

If the denial stands, you have the right to appeal. The first step is an internal appeal, where you ask the insurance company to review their decision. To do this, you’ll need to write an appeal letter and include:

• Your name, insurance ID number, and contact info
• The date of the service and claim number
• A clear statement that you are appealing a denial
• A detailed explanation of why you believe the service should be covered
• Supporting documents (doctor’s notes, letters of medical necessity, research, or even a corrected claim from your provider)

Most insurance companies have an appeal form on their website, or they’ll send you one if you call. Follow their instructions exactly, and send your appeal via certified mail or through their secure portal to confirm it was received.

Step 6: Escalate to an External Review if Needed

If your appeal is denied again, you may have the right to request an external review. This is when an independent third party—outside of your insurance company—reviews the decision.

External reviews are legally binding, and your insurer has to accept the outcome. They’re available for certain types of denials, especially those involving:

• Medical necessity
• Pre-existing condition exclusions
• Experimental or investigational treatments
• Emergency services

Check your state’s rules or healthcare.gov for details on how to start an external review.

Step 7: Watch Your Deadlines

Each stage of the appeal process has deadlines. Don’t miss them. Insurance companies often require:

• Appeals to be filed within 180 days of the denial
• External reviews to be requested within 4 months of a final decision

Mark your calendar and set reminders if needed. This process is paper-heavy and time-sensitive.

Step 8: Don’t Pay the Full Bill (Yet)

While your appeal is pending, don’t rush to pay the full balance—especially if it’s thousands of dollars. Inform your provider’s billing office that you’re appealing the denial and ask them to pause collections until the process is complete. Most offices are used to this and will give you time.

If your appeal fails and the charge stands, you can often negotiate the bill down or set up a payment plan. But don’t make payments prematurely, especially if the claim could still be overturned.

Common Reasons Claims Get Denied (and What to Do)

Here’s a quick reference for some common denial reasons and how to respond:

Denial Reason	What to Do
Out-of-network provider	Explain if it was an emergency or no in-network option existed
Lack of pre-authorization	Ask if retroactive approval is possible; request appeal with supporting documents
Experimental treatment	Provide research, second opinions, and medical necessity letters
Incorrect coding or billing error	Ask provider to resubmit the corrected claim
Service not deemed necessary	Submit doctor’s note or appeal explaining the medical need

Final Thoughts

A denied health insurance claim isn’t the end of the road—it’s the start of a process you have every right to challenge. Understanding your benefits, staying organized, and following up consistently can make a big difference in how things turn out. Yes, it’s frustrating. Yes, it takes time. But fighting a denial now can save you serious money—and teach you how to advocate for yourself in a health care system that doesn’t always make it easy.