My Insurance Denied My Claim — What Do I Do?

Getting a claim denied can feel like hitting a wall — especially when you needed that care. But a denial is not final. You have rights, and appeals succeed more often than people realize.

First: Understand Why It Was Denied

The denial letter must include the specific reason. Common reasons include:

• Service not covered under your plan
• Prior authorization wasn't obtained
• Provider was out-of-network
• Coding error (wrong diagnosis or procedure code)
• Medical necessity not established
• Duplicate claim

The reason determines your next step.

Step 1: Internal Appeal

File an internal appeal with your insurance company. You typically have 180 days from the denial notice. Write a clear letter explaining why the denial was wrong, and attach supporting documentation — your doctor's notes, clinical guidelines, the care plan. Have your doctor write a letter of medical necessity.

Step 2: External Review

If your internal appeal is denied, you can request an independent external review. A third-party organization — not your insurer — reviews the case. This process is free and available to you by federal law. Insurers overturn about 40% of externally reviewed decisions.

Step 3: State Insurance Commissioner

If you believe the denial violates state insurance laws, file a complaint with your state's Department of Insurance.

Practical Tips

• Keep every piece of correspondence — dates, names, reference numbers
• Ask your doctor's office to help — they deal with this regularly and often have staff dedicated to appeals
• Be persistent. Many denials are overturned simply because the patient followed through