Receiving a denial letter from your health insurance provider can be frustrating, especially when you’re counting on that coverage for necessary medical care. However, a denied claim isn’t the end of the road — you have the legal right to appeal. Understanding the process and acting quickly can significantly improve your chances of getting your claim approved.
In this article, we’ll walk you through the reasons claims get denied, how to appeal a denied health insurance claim, and tips for making a strong case.
What Is a Health Insurance Claim?
A health insurance claim is a request made by you or your healthcare provider to your insurance company to pay for medical services covered under your health plan. This can include doctor visits, hospital stays, lab tests, prescription medications, and procedures.
Why Health Insurance Claims Get Denied
Before filing an appeal, it’s important to understand why your claim was denied. Common reasons include:
1. Lack of Medical Necessity
The insurer may determine the treatment wasn’t medically necessary based on their internal guidelines or policies.
2. Out-of-Network Provider
Services performed by doctors or facilities outside your insurance network may be partially or fully denied.
3. Incorrect or Incomplete Information
Missing documentation, incorrect billing codes, or administrative errors can result in a denial.
4. Pre-Authorization Required
Some procedures require prior approval, and if not obtained, the claim may be denied.
5. Policy Exclusions or Expired Coverage
The treatment might not be covered under your specific plan, or your policy may have lapsed.
Step-by-Step Guide to Appealing a Denied Claim
Step 1: Review the Denial Letter
Your insurance company is required to send an Explanation of Benefits (EOB) or denial notice explaining:
- Why your claim was denied
- The specific part of your plan that supports the denial
- How you can appeal the decision
- The deadline for filing an appeal (usually 30–180 days)
Step 2: Contact Customer Service
Call your insurer’s customer service to clarify the reason for denial. Sometimes, issues can be resolved with a phone call if the denial was due to a simple mistake, such as a coding error or missing form.
Take notes, including:
- The date and time of your call
- The name of the representative
- Details discussed
Step 3: Gather Supporting Documents
The success of your appeal depends largely on the evidence you provide. Collect the following:
- Medical records and test results
- Doctor’s letter of medical necessity
- Any pre-authorization letters or referrals
- A copy of your insurance policy and benefits summary
- Original bills and the denial notice
Writing the Appeal Letter
What to Include
A well-written appeal letter should be clear, respectful, and fact-based. Include:
- Your personal and insurance details: Full name, policy number, claim number.
- Description of the treatment: What was done, when, and by whom.
- Why the treatment was necessary: Include the doctor’s reasoning and evidence.
- Refute the denial reason: Address the insurer’s explanation with facts.
- Request for action: Ask for reconsideration and reimbursement.
Sample Opening
Subject: Appeal for Denied Claim [Claim Number]
Dear [Insurance Company Name],
I am writing to formally appeal the denial of my claim for [treatment/procedure] received on [date]. This treatment was medically necessary, as supported by my physician, and should be covered under my current health plan.
Step 4: Submit the Appeal
Where and How to Send
- Appeals can often be submitted by mail, online, or via fax.
- Use certified mail or request a delivery confirmation to track your submission.
Include
- Your appeal letter
- All supporting documents
- A copy of the original denial notice
Keep copies of everything you send.
Step 5: Follow Up
Insurance companies typically have 30 to 60 days to respond to an internal appeal. If you don’t hear back within this time:
- Call the insurer to check the status.
- Ask if they require additional documentation.
What If the Appeal Is Denied Again?
Request an External Review
If your internal appeal is denied, you’re entitled to an external review by an independent third party. This process is available under U.S. federal law and many other health systems worldwide.
- Submit your request within the deadline (usually 4 months from the final denial).
- The external reviewer’s decision is binding, meaning the insurer must accept it.
Consider Legal Advice
If the external review fails and you still believe you’re being treated unfairly, consider:
- Contacting your state’s insurance department or consumer protection agency.
- Speaking with a health law attorney for further action.
Tips for a Successful Appeal
- Act Quickly: Stick to deadlines. Late appeals are often automatically denied.
- Be Thorough: Provide complete documentation and clear arguments.
- Stay Organized: Keep copies of everything — letters, forms, emails, and call logs.
- Get Help from Your Doctor: A letter from your physician explaining the necessity of the treatment carries weight.
- Remain Polite and Professional: Emotional language weakens your appeal. Stick to facts.
When Not to Appeal
Sometimes, an appeal may not be worth the effort. Consider skipping an appeal if:
- The denied treatment is clearly listed as a policy exclusion.
- You knowingly went out of network without coverage.
- The cost of the treatment is low, and the appeal process is lengthy or expensive.
Conclusion
Having a health insurance claim denied can be discouraging, but it doesn’t have to be the final word. With the right approach, documentation, and persistence, many denials can be reversed. Appeals are your legal right, and in many cases, they’re successful — especially when you back up your request with strong evidence and follow the correct procedure. Don’t let the initial “no” stop you from getting the care you need or the coverage you’ve paid for.
Would you like a downloadable checklist or sample appeal letter to go with this article? Let me know, and I’ll