What Patients Should Do When Their Health Insurance Denies a Claim

Understanding Why Claims Get Denied

It is important to know that a denied claim is not the end of the road. In the U.S., patients have clear rights when an insurer refuses to pay for care. Your health insurer must explain why a claim was denied. They need to outline the evidence and reasoning used, as well as provide clear instructions on how to dispute their decision. 

Denials often stem from administrative issues. Missing documents or coding errors. It is often not an actual determination that care should not be covered. Patients have the right to challenge these decisions, and the process is easier and more structured than many realize.

Step 1: Review the Denial Notice Carefully

Every denial must include a written explanation. This notice should state:

• the specific reason for the denial

• the policy rule or guideline used

• what information is missing

• how to file an appeal

• the dates and timelines for appealing

Patients should keep copies of all documents, including Explanation of Benefits (EOBs), denial letters, and any communication with the insurer.

Step 2: File an Internal Appeal

Every patient has the right to request an internal appeal. This requires the insurance company to give your case a full and fair review. During this process, patients can submit:

• letters from treating physicians

• medical records

• additional documentation

• explanations correcting errors

If the situation is medically urgent, the insurer must expedite the review.

Step 3: Request an External Review if Needed

If an internal review has taken place and your case was denied again, you have the right to an external review. An external review is done by an independent third party. Furthermore, the insurer is legally obligated to accept the reviewer’s decision. External reviews are available for:

• denials involving medical judgment

• denials claiming treatment is experimental

• cancellations based on alleged application errors

Why Appealing Matters

A denial is not a final decision. And, many denials are overturned once challenged. External review laws were created to ensure that insurers do not have the final say over medically necessary care.