How To Fight Back When Your Health Insurance Plan Denies a Claim

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A question most Americans have when visiting the doctor: Will my insurance cover it?

Healthcare can be extremely expensive, and an unexpected bill can throw off your entire budget, especially if you expected your insurance to cover it and they denied the claim. In a 2024 survey by The Commonwealth Fund, 17% of respondents said that their insurance company denied coverage for care that was recommended by their doctor — and the majority did not challenge that denial.

You have certain rights when it comes to health insurance claim denials. HealthCare.gov says your insurance company must tell you why they denied your claim and how you can dispute their decision.

If you’re worried about affording medical expenses, learn how to plan for them in advance.

Why Health Insurers Deny Claims

Health insurers can deny claims for various reasons, but Experian’s 2024 State of Claims report found that the top three reasons were missing or inaccurate data, authorizations, and inaccurate or incomplete patient information. Other challenges, including coding errors, staff shortages, missing coverage and late submissions were also to blame.

Although Americans have the right to challenge denied claims, many aren’t aware that they can.

The Commonwealth Fund survey found that the most common reason for not challenging a bill was a lack of awareness about their right to do so, particularly among younger adults and those with lower incomes. However, nearly two out of five respondents who challenged their bill said that their insurer ultimately reduced or eliminated it.

You Have a Right To Appeal a Denied Claim

According to HealthCare.gov, if your health insurer refuses to pay a claim, you have the right to appeal the decision. There are two ways that you can appeal a denied claim:

1. Internal appeal: You can ask your insurance company to conduct a full and fair review of the decision.
2. External review: You can take your appeal to an independent third party for review. This means your insurance company doesn’t get the final say over whether to pay a claim.

The coverage denial letter should list out the steps you should take when making an appeal. According to the Patient Advocate Foundation, if your claim is denied, the insurer must provide the following in writing:

• Information on your right to file an appeal
• The reason your claim was denied
• Instructions on submission requirements
• Deadlines to submit your appeal
• Information on a Consumer Assistance program, if one is available in your state.

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How To Appeal a Health Insurance Claim Denial

You have 180 days from the day you receive notice that your claim was denied to file your internal appeal, according to HealthCare.gov. To file an internal appeal, you need to:

1. Complete all forms required by your health insurer or write to your insurer with your name, claim number and health insurance ID number.
2. Include copies of all necessary documentation in your appeal, such as the Explanation of Benefits forms or letters showing what was denied; a copy of the request for an internal appeal that you sent your insurance company; additional information that you want your insurer to consider, such as a letter from your doctor and dates of phone conversations you had with your insurance company or doctor related to your appeal.
   • Send the original request for the internal appeal to your insurer and keep the copy, but for all other documents, keep the originals and only send copies.
3. If your state has a Consumer Assistance Program, it can also file the appeal on your behalf.

Requesting an External Review

If your insurance company still denies your claim, you can file for an external review. If you have an urgent health situation, you can also ask for an external review at the same time as your internal appeal.

The process for requesting an external review varies by state, but the information you need should be in your Explanation of Benefits; it should also be included in the information you receive when your internal appeal is denied.

When To Expect Answers

Your insurer must complete an internal appeal within 30 days of your filing if it’s for a service you haven’t received yet, according to HealthCare.gov. If you’ve already received the service, internal appeals must be completed within 60 days.