You can usually challenge a denied health insurance claim. Find the denial reason on your Explanation of Benefits, ask your provider's billing office to check for coding errors, and file an internal appeal before your plan's deadline, often 180 days. An external review is your next option if that fails.
Insurers selling HealthCare.gov plans denied 19% of in-network claims in 2024, and patients appealed fewer than 1% of those denials, according to KFF. Plenty of people probably just pay. Maybe that letter's on your counter right now, full of codes you don't recognize.
A few phone calls and a solid appeal could get your money back.
What Does Your Health Insurance Claim Denial Actually Say?
Your Explanation of Benefits is typically the first paper you'll get in the medical insurance claim process after a visit. It shows how much your plan paid and the reason it gave for any denial.
Check the Basic Details
Small errors, like a wrong date of service, can lead to a denial. Make sure every detail matches your own records, from the patient name to the claim number. Then find the appeal deadline and write it on your calendar.
Find the Stated Reason
The letter should name a reason, like "out of network" or "deductible not met." That phrase pretty much decides your next step. A coding problem sends you to the billing office, and a medical necessity denial means you'll need your doctor's help.
Could a Billing Error Be the Real Problem?
Providers send medical claims to your insurer with a code for every diagnosis and procedure. One wrong digit can make the insurer reject the whole thing. In fact, administrative issues like duplicate or incomplete claims made up 25% of in-network denial reasons in 2024 HealthCare.gov plans, according to KFF.
Call your provider's billing office and ask for an itemized bill. Go through it line by line with the person on the phone, and ask:
- Whether they billed your current plan with the right member number
- Whether the codes match the care you actually received
- Whether your visit needed prior approval and they got it
- Whether another insurance plan should have paid first
If the office finds a mistake on its end, ask it to send a corrected claim to your insurer. If the bill checks out, move on to the next step.
Contact Your Insurer and Write Everything Down
Next, call the member services number on your insurance card. Ask the representative which plan rule or medical policy the insurer used to deny the claim. Then ask what paperwork would change the decision.
Write down the representative's name and the call reference number each time. Ask for the answer in writing, too, since you can attach a written statement to your appeal.
How Do You File an Internal Appeal?
An internal appeal asks your insurer to review its own decision. You can use the insurer's appeal form or write your own request with your claim number and member number at the top.
Send it before the deadline, and pick a mailing method that gives you proof of delivery.
How to Get Medical Records for Your Appeal
Your health records show the insurer what happened at your visit and why you needed the care. If you're unsure how to get medical records, start with your patient portal or the front desk at your provider's office.
What to Send With Your Appeal
A letter from your doctor tends to help the most, especially for "not medically necessary" denials. Ask them to describe your medical history and explain why this treatment made sense for you.
Keep your originals and send copies of:
- The denial letter and your Explanation of Benefits
- Your doctor's letter and the records you collected
- Proof that the provider fixed a billing error, if that applies
- A short note in your own words explaining why the denial seems wrong
What if the Insurer Rejects Your Appeal?
In many cases, you can ask for an external review next. An independent reviewer outside the insurance company looks at your case and decides whether the denial holds up. Your final denial letter should explain whether you qualify and how to apply.
Your state's Consumer Assistance Program can answer questions about your plan and the appeal steps. Some states don't have one, so in that case, call your state insurance department instead.
Some employers pay health claims with their own money, and if yours does, contact the plan administrator too. For a bill in the thousands, a talk with an attorney familiar with healthcare regulations could be worth it.
Frequently Asked Questions
Can Someone Else File an Appeal for Me?
Yes, another person, like your doctor or a relative, can file the appeal for you. You'll probably need to sign a form that names them as your representative. Your state's Consumer Assistance Program might be able to file one for you, too.
How Long Does My Insurer Have to Decide?
Insurers get 30 days to decide an appeal for care you haven't received yet, according to HealthCare.gov. For care you've already had, they get 60 days.
What if I Need Care Right Away?
You can ask for an urgent appeal, and your insurer has to decide within four business days at most. You can request an external review at the same time, and that review gets a decision within 72 hours or less.
How Long Do I Have to Request an External Review?
You get four months from the date you receive your insurer's final denial. HealthCare.gov says you have to send the request in writing, so mark the date on your calendar the day the letter arrives.
Put Your Appeal Plan to Work
Winning a health insurance claim appeal mostly depends on paperwork and timing. Find the exact denial reason on your EOB, ask the billing office to fix any coding or ID mistakes, and send a complete internal appeal with your clinician's support before the deadline.
If the insurer upholds the denial, an independent external reviewer can look at your case, and your state insurance department can help if you get stuck. Keep every letter, receipt, and call reference number in one folder.
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