My Insurance Denied My Claim — What Does That Mean and What Do I Do?

A claim denial means your insurance company did not pay for a service. It is not the final word. The most common reasons are missing prior authorization, an out-of-network provider, or a billing code error — and most of these are fixable. You have the legal right to appeal any denial, and your EOB will include the reason code and appeal instructions. If you are not sure where to start, tell Cura what your denial says and we will explain it and tell you what to do next.

The most common reasons claims get denied

• Prior authorization not obtained — some services require approval before they happen.
• Out-of-network provider — if your provider is not contracted with your plan, the claim may be denied or paid at a lower rate.
• Not medically necessary — your insurer may determine a service did not meet their clinical criteria.
• Billing code error — a wrong code is one of the most common and most fixable reasons for denial.
• Duplicate claim — if the same claim was submitted twice, the second will be denied.
• Eligibility issue — if your insurance was not active on the date of service, the claim will be denied.

How to read your denial on the EOB

Your EOB will show a reason code next to the denied service and include instructions for how to appeal. Write down the reason code before calling anyone — it is the starting point for resolving the denial.

The appeal process step by step

1. Request an itemized bill from your provider.
2. Call your insurance company and ask them to explain the denial reason in plain language.
3. Ask your doctor's office if a letter of medical necessity is needed.
4. Write a brief appeal letter stating why the service was appropriate and medically necessary.
5. Submit the appeal before the deadline — usually 60 to 180 days from the denial date.
6. Request written confirmation of your submission.
7. If your internal appeal is denied, ask about external independent review — this is a legal right under the Affordable Care Act.

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Related Cura guides

• Understanding your medical bill or EOB
• What is an Explanation of Benefits
• Waiting for results

This page is educational information only and is not legal, financial, or billing advice. For questions about a specific bill or insurance decision, contact your provider's billing department or your insurance company's member services line. If you believe you have been billed incorrectly or denied coverage unfairly, a licensed patient advocate or healthcare attorney can provide advice specific to your situation. If this is a financial emergency, contact your provider's financial assistance office — most nonprofit hospitals are required to offer charity care programs.