What to Do When Your Health Insurance Claim Is Denied

Start with the denial notice

Save the full notice, including the appeal instructions. Match it to the provider, patient, service date, and claim number. A provider bill and an insurer decision may arrive separately. Ask for the explanation of benefits (EOB) if you only have a bill.

• Write down when you received the denial and the stated appeal deadline.
• Highlight the reason code and the plain-language explanation.
• Check whether the decision concerns future care or services already received.

Choose the right next step

Ask the insurer what information would change the decision. If a name, insurance ID, or submitted claim detail is wrong, ask the provider to investigate a corrected claim. If the disagreement is about coverage or clinical criteria, an appeal may be needed.

• Missing or incorrect claim information: contact the billing office.
• Medical necessity: involve your treating clinician.
• Other insurance listed as primary: confirm coverage dates and coordination of benefits.
• Out-of-network decision: verify the provider and facility network status for that date.

Make two practical calls

Ask the insurer for the exact plan provision it relied on and where to send a challenge. Ask the provider whether it can supply missing records or correct the claim. Request a billing hold while the issue is reviewed; get confirmation rather than assuming it is automatic.

Keep your appeal rights open

A phone call, corrected claim, or provider review may not count as your formal appeal or extend its deadline. Follow the notice’s submission instructions. Keep proof of delivery and copies of everything you send. If care is time-sensitive, ask your clinician and plan about expedited review.