Health Insurance Claim Denied: What to Do Next

Health insurance claim denied: what to do in step 1

Put the denial letter beside your Explanation of Benefits, often called an EOB. The EOB explains how the insurer processed a claim. It is not itself a bill. A provider's bill may arrive separately, and the amounts may need to be reconciled before you know what you owe.

Find the service date, provider, claim number, amount denied, and reason code. Check whether the notice concerns care already received, a request for approval before treatment, or a cancellation of coverage. These are different situations, and the next steps may differ.

If the reason is written in shorthand, call the number on the notice. You can say: "Please explain the exact reason this claim was denied, and the plan rule used to make that decision." Ask for a written explanation if the notice does not make it clear.

Health insurance claim denied: what to do about deadlines in step 2

Deadlines vary by plan. Check the denial letter for the exact dates. Also check whether the filing window runs from the notice date, the date you received it, or another event. Ask how the plan counts the days and whether it must receive your appeal by the deadline.

Write the date somewhere you will see it. Requesting records, calling the insurer, or waiting for the doctor's office does not necessarily pause an appeal deadline. If the letter and plan documents disagree, ask the plan administrator to clarify the instructions promptly and in writing.

For the internal appeals it describes, HealthCare.gov gives a general filing period of 180 days. Do not assume that number applies to your coverage. Medicare, Medicaid, certain workplace plans, and other programs may follow different procedures.

Step 3: Match the next step to the reason

A claim can be denied for several reasons. The reason matters because an appeal should address the actual problem, rather than simply saying the bill is too high.

• Missing information or a coding error: Ask the provider's billing office whether it can correct and resubmit the claim. Confirm whether you still need to file an appeal to preserve the deadline.
• Medical necessity: Ask your clinician whether relevant records or a clinical explanation can address the insurer's stated criteria.
• Prior authorization: Ask whether authorization was requested, what decision was made, and what review or appeal process applies.
• Out-of-network care: Check the plan's network rules and ask whether any exception or surprise-billing protection may apply. Not every out-of-network charge qualifies for a protection.
• Coverage or eligibility: Ask which plan provision is involved and whether the insurer's information about your coverage dates is correct.

Keep the denial letter even if someone says the problem is being fixed. Follow up until you receive an updated claim decision or written confirmation.

Step 4: Gather a small, useful set of records

Begin with the denial notice, EOB, provider bill, and the relevant part of your plan's coverage documents. Request the records that explain the disputed service. For a clinical denial, your doctor may be able to provide notes, test results, or a letter explaining why the care was appropriate.

You do not need to send every record you have without checking relevance. A focused set of documents is easier to review. Make a simple index naming each document and its date. Keep originals and submit copies unless the plan specifically instructs otherwise.

For many private-sector workplace plans, the Department of Labor explains that people can request documents relevant to a benefits claim. Ask the plan administrator which materials are available and how to obtain them.

Step 5: Keep a call log and proof of submission

Write down the date, representative's name, reference number, and what was said during each call. Save portal messages and letters. If a provider resubmits a claim, ask for the new claim reference and expected review date.

If you appeal, follow the instructions in the denial notice. Keep an exact copy of what you send and evidence that it arrived. A correction request and a formal appeal are not necessarily the same thing. Ask the insurer which process is underway.

Step 6: Get help without waiting out the clock

Your state insurance department or Consumer Assistance Program may help you understand your options. For many private-sector employer plans, the Department of Labor's Employee Benefits Security Administration is another source of assistance. Coverage programs such as Medicare and Medicaid have their own help and appeal routes.

If delaying care could seriously affect your health, contact your care team and insurer right away about an expedited review. An ordinary document-preparation service is not a substitute for urgent care or an urgent appeal request.

For a more detailed process, read How to Appeal a Denied Health Insurance Claim, Step by Step. If an internal appeal is unsuccessful, our external review guide explains when an independent review may be available.

This guide explains general insurance processes. It is not legal advice. Your plan documents and denial notice determine the steps and dates for your situation.

What the denial and appeal figures tell us

KFF's analysis of 2024 federal data found that insurers offering qualified health plans on HealthCare.gov denied 19% of in-network claims. Fewer than 1% of denied in-network claims were internally appealed. These figures describe that Marketplace population, not all U.S. health insurance.

KFF could not calculate the external-appeal outcome rate because small reported values were suppressed. The data do not establish a two-thirds external-review success rate. Statistics cannot predict the result of your own claim.

Want help organizing the appeal?

For denied claims of $3,500 or more, Cura's paid Denial Appeal Packet service prepares an appeal letter addressing the stated denial reason, a deadline sheet, an indexed evidence appendix, and a submission and follow-up checklist. The internal appeal packet is $349. If it goes to external review, the price is $599. You submit the packet yourself. We are not lawyers and do not provide legal advice.

A person reviews your case, and you keep every dollar you win back.

Start your Denial Appeal Packet

Not sure what the bill or explanation of benefits is saying? Start with Bill Help or use Cura's medical bill and EOB explainer.