Read the denial, then appeal it

The letter says the claim was denied, or the explanation of benefits says “not covered”, and a number that was the insurer’s problem has just become yours. It reads like a verdict. For some of the people behind this page it turned out to be an opening move.

A denied health insurance claim can be appealed: find out the exact reason, fix it if it is a simple error, and if it is not, file an appeal with the insurer and then ask for an independent review.

Some people say the same thing about why this works: insurers count on people taking the first no, and an appeal or a request for review often reverses a denial, because the first decision rested on a small error or was a bluff. Some people describe getting a denial overturned by persisting and escalating. The law behind that is on your side, and in the United States it gives you two appeals: one to the insurer, and one to someone outside it.

First, find out why they said no

The reason is written on the denial or the explanation of benefits, and it decides everything after it. Some people say denials often cite a small administrative detail, and one person’s list is the kind of thing to look for: a wrong procedure code, a doctor’s name missing from a form, the insurer’s internal list disagreeing with its own website. In one case a test was denied as “experimental” though the insurer’s site listed it as covered; in a similar case the cause turned out to be a wrong code from the doctor’s office, fixed once it was resubmitted. One person explains why this happens: the staff who submit authorisations are often trained in patient care, not in coding.

So the first call is often to your doctor’s or the hospital’s billing office, not the insurer. Whose mistake it is matters. In one exchange some people said the anger belongs with the insurer and one that it often lands wrongly on doctors, and what decided it, they said, was whether the problem is a billing error on the provider’s side or a decision by the insurer. The doctor’s office may also be the ally you need later.

Some denials are not errors. One person points out that coverage for a major procedure can require proof of earlier steps — physical therapy, injections — that no summary had mentioned. Another says “100 percent covered” means the insurer pays its own allowed amount, which can be less than what the provider charges. One person points out that a “covered” answer never told you the cost anyway. And the documents that settle what your plan says are its full policy or, for an employer plan, its summary plan description. One person answered a complaint that insurance covers almost nothing by pointing to that document, which sets out the coverage percentages, the deductible and the out-of-pocket maximum, even where it does not list every procedure. Some people name the actual policy documents, or the summary plan description, as what you need in hand. You do not need to read the whole thing — find the section that matches the reason on the denial.

Expect it to be slower than it should be. One person was sent the wrong denial letter each time and spent six months calling the insurer and their employer’s human resources before finding the real reason, and still had no claim accepted. One person warns denials can persist for months even after the right reason is found, and one person says different representatives give different answers. One person says phone staff avoid the word “covered” and say “considered” instead. Keep a written record of every call.

The two appeals the law gives you

The first is an internal appeal: you ask the insurer to take a full and fair second look. The US government’s health insurance site says you must file it within 180 days of being told the claim was denied, and that the insurer must decide within 30 days if you have not had the care yet and within 60 days for care you have already had. For an urgent case the site says as fast as your condition requires and no later than 4 business days; the Labor Department’s rules for employer plans say no later than 72 hours. For an employer plan, the US Department of Labor adds two rights worth using: the plan must give you, free, copies of the documents and records relevant to your claim, and you can ask for the identity of any medical expert whose advice it obtained. That is the real, narrower version of a viral claim that you can demand the names and credentials of everyone who touched your file; some people say that claim is overstated. Ask for the claim file; it shows you what they looked at.

What makes an appeal strong, from people: a doctor who will argue for you. Some people name a doctor willing to advocate as something you need, and one person says a doctor’s letter of medical necessity, or a doctor-to-doctor call with the insurer, can significantly strengthen a claim — they name orthopaedic doctors. One person says that after two or three denials a case can become that kind of call — a nurse or someone from the doctor’s office speaking directly to the insurer — and that it usually gets approval. Another says simply resubmitting the same claim only produces a duplicate denial; the claim has to be corrected, or appealed. The doctor-to-doctor call has its critics too: one person says it is useless when the insurer is applying a rigid rule of its own — a stricter weight threshold than the US Food and Drug Administration uses, in their example — that no doctor can argue away, and another says these calls cost doctors unpaid time, often with a reviewer outside their specialty. What decides it, they said, is whether the denial is about a medical judgement, which a doctor can argue, or about a fixed policy rule, which a doctor cannot.

The second is an external review. If the insurer says no again, you can ask an independent reviewer outside the company to decide — when the denial turns on a medical judgement, such as whether the care was necessary or is “experimental”, or when your coverage was cancelled; those are the cases the government’s site lists, and your notice says whether yours qualifies. The US government’s site says you must request it in writing within four months of the final denial, that the insurer is required by law to accept the reviewer’s decision, and that a standard review is decided within 45 days and an urgent one within 72 hours. It is free under the federal process and costs up to $25 in some states. Some older plans that have not changed since before 2010 may not offer it; your denial notice says which process applies to you, and it is the document to follow.

When to go over their heads

Some people say a complaint to your state’s insurance department — the insurance commissioner — works as the next step when an insurer will not pay a claim it owes. One person describes an insurer that did nothing until the doctors went to the state regulator, and even then the regulator told them the insurer had no legal duty to pay, in that state. One person notes that nobody in that conversation confirmed a complaint had actually resolved their case, and in one exchange some people said it works because insurers want to avoid a regulator’s attention, against one who expected it to fail, since insurers rely on people not going to court.

One thing to check before you send it, because it changes where it goes: a state insurance department regulates insurance companies, so it covers plans that an insurer sells or runs, but not an employer’s self-funded plan, where the employer pays the claims itself and an insurance company only administers them. The national association of state insurance regulators says states cannot treat those plans as insurers. For those, the US Department of Labor’s benefits agency can help, on 1-866-444-3272. Your employer’s benefits office, or your plan document, can tell you which kind you have. The US health department’s own checklist for a denied claim names, alongside the appeals: your state’s consumer assistance program, which helps people with exactly this; a patient advocate; your state insurance department; and the Department of Labor for employer plans. One person says asking your member of Congress for help is useful; others said they got no answer, or that it felt like damage control.

If the bill is from someone you never chose

Some people describe the same shock: a separate bill after surgery or a hospital stay, from an anaesthetist, a nurse or a technician who was not in the insurer’s network, and some people say pushing back — you had no choice of provider, or it was an emergency — can sometimes get it dropped, though it is a burden. One person says making a fuss over an out-of-network radiologist at an in-network facility can get the fee written off. That fight is now mostly the law’s. Some people name the federal No Surprises Act, and one person confirms it is national, not a state-by-state patchwork. The US health department says that since 1 January 2022 it protects you from surprise out-of-network bills for most emergency care, for care from out-of-network providers at an in-network hospital or facility, and for air ambulances, and that in those cases you cannot be charged more than your plan’s in-network share. Providers can sometimes ask you to sign a form giving up that protection for planned care — one person says patients can still be given a bill just before an operation, even after signing the forms — but they are not allowed to ask for it for anaesthesia, pathology, radiology, diagnostic tests, emergency care, neonatal care, assistant surgeons, hospital doctors or intensive-care doctors. One person dates the law to August 2022; the health department’s date is 1 January 2022. The gap to know about: a ground ambulance is generally not covered by the federal law, unless your state has its own rule. The No Surprises Help Desk is 1-800-985-3059.

While it is being fought

The bill does not stop arriving while you appeal. Some people say an uncovered medical bill is negotiable, and that asking for a lower price often gets one; this site has a whole page on questioning a hospital bill before you pay it, including the financial assistance non-profit hospitals are required to offer. One person’s experience is that multiple bills — hospital, pharmacy, radiology — got resolved each time they kept pushing. Some people are honest about the cost: you end up acting as your own unpaid billing clerk, with a spreadsheet and a weekly check. That is a real burden, and it is part of what fighting a denial costs.

Is the system rigged against you?

Some people say the system is built to be opaque and confusing, so that it makes money from denials, and two say insurers deny claims because paying them costs money. In one conversation the argument split three to three: some said it is legal theft and should not need a fight at all, others that it is navigable once you know the rules. What decided it, they said, was whether you see the paperwork as a puzzle you can solve or as an injustice in itself. You can believe both and still file the appeal. Some people are honest about the odds: one notes that a person here who described fighting successfully works in the industry, so their success may rest on knowledge a patient may not have, and another says even people who work in insurance struggle to get claims paid. These accounts were written by people who kept going; the people who gave up after the first letter are not here to say how it went, and some who fought to the end still lost.

Who this page is not for

If you are on Medicare or Medicaid, the rights above are not the ones that apply, and your notice sets out your own process. Original Medicare has five levels of appeal, with the first deadline printed on your Medicare Summary Notice; one person here listed them from memory and said to check. If you are dual-eligible and in a nursing facility, one person notes that changing plans may be possible, depending on your Medicaid level — that is a question for your state’s Medicaid office or a benefits counsellor.

If you left insurance for a health-sharing ministry, as one person here urged, none of these appeal rights apply: the state insurance regulators’ association says those arrangements are not insurance, cannot guarantee to pay, and do not have to follow the Affordable Care Act’s protections.

If the claim that was denied is on your home or car insurance, this page is not about you; those policies work differently, and a long argument about reading them is left for another page.

And outside the United States, none of this applies. In the UK, most care is through the NHS, and if a private medical insurer turns down a claim, you complain to the insurer first and, if it does not put things right within eight weeks or you disagree with its answer, you can take it to the Financial Ombudsman Service. Elsewhere, your country’s insurance regulator or ombudsman is where to start.