PolicyZenPolicyZenGetting a claim denied feels like hitting a wall. But it's not the end of the road — it's the beginning of a process that you can win more often than you think.
The data is clear: a meaningful percentage of denied claims are overturned on appeal. The reason most people don't win isn't that their case is weak — it's that they don't appeal at all. Most people accept the denial and pay. Insurers count on this.
| Reason | What It Means |
|---|---|
| Not medically necessary | Insurer doesn't agree the treatment was required |
| Missing prior authorization | Approval wasn't obtained before the service |
| Out-of-network provider | Provider not in your plan's network |
| Service not covered | The specific treatment isn't in your plan |
| Coding error | Wrong billing code submitted by the provider |
| Duplicate claim | Same claim submitted more than once |
| Coordination of benefits | You have multiple plans; insurer disputes who pays first |
| Policy lapsed | Coverage wasn't active on the date of service |
Request a written Explanation of Benefits (EOB) or denial letter that states the specific reason for denial and the criteria used. You cannot appeal effectively without knowing exactly why you were denied.
The denial reason dictates your entire appeal strategy. "Not medically necessary" requires clinical evidence. "No prior auth" may require a retroactive auth request. "Not covered" requires a careful reading of your plan documents. Different reasons need different responses.
You need: your EOB or denial letter, your policy documents, your medical records relating to the denied service, any supporting clinical evidence (treatment guidelines, peer-reviewed studies), and a letter of medical necessity from your doctor.
This is your most powerful tool and most people don't know it exists. Your doctor can call the insurer's medical director directly to discuss the case physician-to-physician. These calls frequently result in reversals. Ask your provider's office to request one immediately.
Submit your written appeal with all supporting documentation to your insurer before the deadline (typically 180 days from denial for health insurance). Include: a cover letter stating your case clearly, the letter of medical necessity, clinical evidence, and any plan language supporting coverage. Be specific and reference your exact policy language.
Under the ACA, you have the right to an independent external review by a third party not affiliated with your insurer. External reviewers overturn insurer decisions at meaningful rates. For urgent medical situations, expedited external review decisions must come within 72 hours.
If external review fails or isn't available, file a complaint with your state's insurance commissioner. This creates a regulatory record and sometimes prompts insurers to reconsider. For employer-sponsored plans governed by ERISA, your recourse is federal court rather than the state commissioner.
Upload your insurance policy to PolicyZen. Know exactly what's covered — and have the ammunition you need if a claim gets denied.
Know My Coverage →