How to Successfully Appeal An Insurance Denial

Step 1: Understand why your claim is denied

One of the most important first steps is understanding the reason for the denial.

Your insurance company is required to provide a written explanation. The reasons are typically included in a formal denial letter known as an “Explanation of Benefits” (EOB). Review this document carefully for the specific reason the insurer denied your claim. This may include:

• Not medically necessary: The insurance company determined the service or treatment was not essential for your health condition. Read more on what medical necessity means.
• Not a covered benefit: The service, procedure, or product is not included in your policy’s coverage plan, for any coverage or possibly because of an alternative to a “preferred” item.
• Pre-existing condition: This may involve a claim being related to a health condition you had before your coverage began, in which the insurer does not believe it should have to cover.
• Out-of-Network: The services were provided by a doctor, facility, or company not included in your plan’s network.
• Incorrect coding or missing information: The claim form contained errors, such as a wrong billing code or incomplete details. This may even include key information such as your name, spelling, or date of birth.
• Prior Authorization required: The service required pre-approval, which was not obtained. This may apply to specific types of items or more expensive services or treatments, and your healthcare team may navigate this process without your knowledge. Read more about prior authorization and how to navigate that process.

As many as 20% of insurance claims may be initially denied. That number can be higher for private commercial insurance plans offered by employers, with some research

Step 3: Work with your doctor or healthcare team

Your doctor’s office is your strongest ally in this process, especially if the denial is based on “medical necessity” or coding issues.

• Request a corrected claim: If the denial was due to an administrative or coding error, ask your provider’s office to correct the mistake and resubmit the claim.
• Obtain a letter of medical necessity: If the denial was for medical reasons, ask your doctor to write a letter explaining why the treatment or service was essential for your health. This letter should be detailed and reference your medical history, diagnosis, and what might happen if you don’t receive the treatment.
• Request supporting documents: Your doctor can provide you with medical records, test results, and any other documentation that supports your claim.

Step 4: File an internal appeal

Once you have all your documents and a strong case, it’s time to file an internal appeal with your insurance company. This is the first level of appeal.

• Write a formal appeal letter: The letter should be clear, concise, and factual. Avoid emotional language. Be sure to include:
  • Your name, policy number, and claim number.
  • The date of service and the specific service that was denied.
  • The reason for the denial as stated in the denial letter.
  • A detailed explanation of why you believe the claim should be covered, referencing your policy documents and the supporting evidence you’ve gathered.
  • A list of all the enclosed documents.
• Submit your appeal by the deadline: Pay close attention to the deadline for filing an internal appeal, which is usually included in your denial notice. Send your appeal via certified mail or with a tracking receipt so you have proof of submission.

Step 5: Consider an external review

If your internal appeal is denied, you have the right to request an external review. This means an independent third party, not with your insurance company, will review your case.

• Your insurance company’s final denial notice after the internal appeal should provide information on how to request an external review.
• The external reviewer will examine the documentation and make a binding decision. If they side with you, your insurance company must cover the claim.

Why does this matter?

Insurance claim denials matter because they may prevent people from always getting the health or medical care they might need.

While insurance denials can lead to alternative treatments that may be less expensive for both you and your insurance carrier, research shows that claim denials often lead to people not following through for other coverage or further discussions with their healthcare team after the denial.

Research found that the trend continued in 2024, with 74% of adults expressing they were very or somewhat worried about affording medical bills, and that unexpected medical bills discouraged them from getting future medical care.

This may affect healthcare, especially for those in lower-income and at-risk populations who may need that particular healthcare and are less likely to appeal an insurance denial and get that needed healthcare.

The takeaway

You have the right to appeal an insurance company’s decision to not cover a particular claim.

There is a defined process for appealing an insurance claim denial, and you will want to review your plan documentation for those details. Often, when a claim is denied, your insurance company will send a notice by regular mail explaining the denial reasons and outlining the process to appeal that decision.

You can work with your doctor or healthcare team to appeal an insurance claim denial. They may require certain documentation, including doctor’s notes or medical necessity documentation showing why this item should be approved and covered by insurance.