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Insurers deny claims due to out-of-network care, incomplete paperwork or coverage disputes. You're left with unexpected bills for care you thought was covered.
Fight denied claims through appeals. Identify why the claim was rejected, collect supporting documents and file internal and external reviews to challenge the decision.
Review the Explanation of Benefits (EOB) or denial letter to know why your claim was denied. Terms like "medically necessary" or "out-of-network" are key clues.
Gather documents like the EOB, original claim, medical bills and supporting medical records before starting your appeal.
File an internal appeal within the insurer’s deadline, between 30 and 180 days.
If an internal appeal doesn’t overturn the denial, file an external review with a third party or seek help from a patient advocate.
Look at why your health insurance claim was denied. Gather supporting documents, file an internal appeal and pursue an external review.
Figure out why your insurer denied your claim. Check your Explanation of Benefits (EOB) or denial letter for specific terms. Call your insurer and ask for an explanation. Common reasons insurers deny claims include:
Insurers reject claims if they determine the treatment doesn't meet their medical necessity criteria. This means they see the procedure as optional or believe there are more cost-effective alternatives.
Receiving care from a provider not listed in your plan’s network often results in claim rejections. Many policies limit coverage to in-network providers, even for necessary treatments.
Policies have financial caps on specific treatments. If your care exceeds these limits, the insurer denies further payments, leaving you responsible for the remaining costs.
Claims lacking the required paperwork, such as medical records or supporting notes, are denied. Submitting all required documents helps the insurer assess the claim properly.
Every insurance plan has exclusions. If your treatment falls outside what's covered (like certain alternative therapies or elective procedures) your claim gets denied.
Collect:
Keep everything organized. Use folders (physical or digital) labeled by category.
Track every conversation with your insurer. Write down the date, the representative's name and what you discussed. Set reminders for deadlines so you don't miss critical appeal windows.
An internal appeal asks your insurer to reconsider its decision. You can present new evidence, clarify misunderstandings or challenge the denial using your policy's terms.
You have 30 to 180 days after receiving your denial notice to file an internal appeal. Here's how to file:
If delaying treatment threatens your health or life, call your insurer right away and request an expedited appeal. Explain why it's urgent and get a supporting statement from your health care provider. Insurers must decide within 72 hours for expedited appeals, so write down every conversation and follow up if you don't hear back.
Insurance companies have timelines for responding to appeals. For pending treatments, expect a response within 30 days. For completed treatments, the timeframe is 60 days. Expedited appeals for urgent situations have a 72-hour deadline. Mark these dates on your calendar to track when a response is due.
If you don't hear back by the deadline, contact your insurer by phone or email.
Track every interaction with your insurance company during the appeal process. Keep a log of all communications.
An external review is an independent evaluation of your denied claim by a third party rather than your insurer. An external review offers an unbiased assessment that can overturn the insurer's denial based on your policy details and medical evidence.
You can file an external review if your internal appeal is denied or the claim involves medical judgments (such as determining medical necessity) or policy exclusions impacting your coverage. Check your insurer’s guidelines to confirm eligibility.
If you’re eligible, prepare a concise review request.
To file an external review:
Standard external reviews take about 45 days.
If you have a denied appeal, you can consult a lawyer, file a complaint with state regulators or pursue mediation.
If all appeals fail, consult a lawyer specializing in health insurance law. These professionals review your case in detail, determine if the insurer violated laws and guide you through potential actions like filing a lawsuit. This step works best when you suspect that your rights have been violated or if there are complexities in your case requiring formal legal action.
Submitting a formal complaint to your state's insurance department can lead to an investigation into your insurer's conduct. Each state has an insurance regulator, with complaint procedures available on their website. Make sure to provide complete documentation, including denial letters, policy details and a summary of your appeal efforts, to support your case.
Patient advocates specialize in insurance appeals and can help gather evidence, communicate with your insurer and navigate the appeals process. Contact an advocate if the process feels overwhelming or you're unsure how to proceed.
A neutral mediator can help you and the insurer negotiate a settlement out of court. If mediation fails, litigation is your final option. Lawsuits usually take one to three years and require extensive documentation and legal fees.
Common questions about appealing health insurance claim denials:
Success rates vary, but research shows over 80% of prior authorization appeals result in insurers partially or fully overturning their denials. Your chances depend on why the claim was denied, the strength of your evidence and how thoroughly you build your case.
Start with an internal appeal, file an external review or submit additional information that addresses the denial reason. If those don't work, consult a lawyer, file a complaint with state regulators or try mediation.
Most insurers give you 30 to 180 days from the denial notice date to file an internal appeal. Check your insurer's deadline and act fast.
Call your insurer immediately and ask for an extension — some allow extra time for valid reasons. You can also file a complaint with state regulators or consult a lawyer about other options.
Yes, especially if you have new evidence or additional documentation. Check your insurer's guidelines for the number of appeals allowed and whether you can file an external review after multiple denials.
Explore these MoneyGeek resources to find tips on comparing health insurance, choosing the best plan, reducing medical bills and managing medical debt effectively.
About Nathan Paulus
Nathan Paulus is the Head of Content at MoneyGeek, where he conducts original data analysis and oversees editorial strategy for insurance and personal finance coverage. He has published hundreds of data-driven studies analyzing insurance markets, consumer costs and coverage trends over the past decade. His research combines statistical analysis with accessible financial guidance for millions of readers annually.
Paulus earned his B.A. in English from the University of St. Thomas, Houston.
