Health Insurance Claim Denied? How to Review and Appeal a Decision

A health-plan denial is a decision to investigate, not necessarily the end of the process. It might involve eligibility, a coding or billing error, network rules, medical necessity, prior authorization, or a specific exclusion. Your notice, plan documents, type of coverage, and applicable law determine which review rights and deadlines apply.

1. Identify exactly what was denied

Find the service date, provider, claim number, denial or Explanation of Benefits (EOB) notice, reason code, cited plan provision, and any amount the provider says you owe. An EOB describes claim processing and is not itself a bill. If the provider has sent a bill, compare it with the EOB before paying or disputing an amount. Ask for an itemized bill if needed.

2. Check for correctable errors

Confirm the insurer has the correct member and provider information. Ask the provider whether a diagnosis or procedure code was entered correctly and whether records were missing. Ask the plan which documents support its decision. A correction or reprocessing request may be possible, but do not let an appeal deadline pass while waiting for a billing fix.

3. Request the appropriate internal appeal

Many health plans have a formal internal appeal process. Read the denial notice for the filing method, deadline, and where to send supporting material; do not assume a phone call alone counts as a filed appeal. Explain what decision you dispute, cite the relevant plan terms, and include documents such as medical records or a clinician's explanation when relevant. Keep a dated copy and proof of delivery.

4. Ask whether external review applies

Depending on the plan and the reason for denial, an independent external review may be available after the internal process. Some urgent cases can follow an expedited path. Time limits and eligibility differ, so follow the current notice and official instructions rather than a generic deadline found online. HealthCare.gov has separate guides for internal appeals and external review.

Keep a short appeal record

• Denial notice, EOB, policy or Summary of Benefits and Coverage, and provider bill.
• Claim and reference numbers; dates, names, and summaries of every call.
• Medical evidence, corrected claims, written submissions, and confirmation receipts.
• Each new decision and its deadline for the next step.

For help with the process, contact the plan's appeals department, the applicable state insurance department or consumer-assistance program, or the agency responsible for your coverage. Employer plans, Medicare, Medicaid, and Marketplace coverage can have different procedures. This guide is not legal or medical advice and cannot predict an appeal outcome.

Editorial note: Policy Made Clear provides general education, not personalized insurance, legal, tax, medical, or financial advice. We are not an insurer or agency. The issued contract and applicable law control your coverage.