Fighting Health Insurance Claim Denials

Health insurance companies deny roughly 850 million claims per year in the United States. Fewer than 1% of patients appeal — yet studies show that nearly 44% of internal appeals succeed and the reversal rate for external reviews is even higher. A denial is not a final answer.

Why Claims Are Denied

Common reasons for denial include administrative errors (incorrect billing codes, missing information), lack of preauthorization, a service being deemed “not medically necessary,” or the provider being out-of-network. Understanding the specific reason is the first step toward overturning it.

Step 1: Read the Denial Letter Carefully

The denial letter must explain why the claim was denied and provide instructions for appealing. Note the deadline — under the Affordable Care Act, you typically have 180 days from the denial notice to file an internal appeal. Don’t let this window close.

Step 2: Internal Appeal

File a formal internal appeal with your insurance company. Your appeal should include:

• A clear written explanation of why the denial is incorrect
• A letter of medical necessity from your physician explaining why the treatment is appropriate and evidence-based
• Relevant medical records, test results, and clinical guidelines that support your case
• Your policy documents showing the benefit should be covered

The insurer must respond within 30 days for pending treatments or 60 days for services already received. For urgent care, the deadline is 72 hours.

Step 3: External Review

If your internal appeal is denied, you have the right to an independent external review by a third-party organization. This review is free and the decision is legally binding on the insurer. Denials involving medical judgment, experimental treatments, or retrospective coverage cancellations are typically eligible.

Additional Resources

• Your state Department of Insurance can investigate complaints and assist consumers
• Patient Advocate Foundation offers free case management services for complex appeals
• For individuals with disabilities, disability-specific advocacy organizations often have staff experienced in fighting coverage denials for therapies, assistive technology, and durable medical equipment