Getting a claim denial letter in the mail feels like a punch to the gut. You’ve been dealing with medical bills, recovery stress, and now your insurance company is telling you they won’t pay for care you thought was covered. You’re not alone—insurers denied nearly one out of every five claims submitted for in-network services in 2023, according to KFF’s analysis of 2023 marketplace plans.
The truth is, claim denials happen more often than most people realize. But here’s the thing: a denial doesn’t have to be the final answer. Many denials can be successfully challenged if you know the right steps to take. Below, our friends at Warner & Fitzmartin – Personal Injury Lawyers explain what to do if your insurance claim is denied.
Why Claims Get Denied In The First Place
Understanding why your claim was rejected is the first step toward fixing it. According to KFF, the most common denial reasons include administrative issues (18%), excluded services (16%), and lack of prior authorization or referral (9%). Administrative problems alone—things like duplicate claims, missing information, or untimely submissions—make up a huge chunk of denials.
Sometimes it’s a simple billing error. Your doctor’s office might have used the wrong procedure code or forgotten to include necessary documentation. Other times, your insurer claims the service isn’t covered under your policy or wasn’t medically necessary. And occasionally, there’s confusion about whether you were actually covered at the time you received care.
The frustrating part? According to KFF, about 34% of denials fall into an “other” category, which doesn’t give you much to work with when you’re trying to figure out what went wrong.
Don’t Just Accept The Denial
Here’s something insurance companies are counting on: fewer than 1% of denied claims are appealed, according to KFF. That means millions of people every year receive denial letters and simply give up or pay out of pocket rather than fighting back.
But the numbers tell a different story. More than half of denied claims—about 52%—are eventually overturned and paid when providers and patients challenge them, according to a 2024 Premier Inc. survey of hospitals and health systems. That’s a pretty compelling reason to push back instead of accepting the first “no” you receive.
Read The Denial Letter Carefully
Your denial letter should explain why your claim was rejected. Look for specific reasons like “not medically necessary,” “services not covered,” “lack of prior authorization,” or “out-of-network provider.” This explanation is your roadmap for what to do next.
Check the deadline for filing an appeal—it’s usually 30 to 180 days depending on your plan and state regulations. Missing this deadline could mean losing your right to challenge the decision, so mark it on your calendar immediately.
Gather Your Documentation
Before you file an appeal, you’ll need to build your case. Start by requesting your complete medical records related to the denied service. Get a letter from your treating physician explaining why the treatment was medically necessary and appropriate for your condition.
Dig out your insurance policy and read the section that covers the service you received. Sometimes insurers deny claims based on misinterpretations of policy language. If your policy says the service should be covered, that’s ammunition for your appeal.
Look for any pre-authorization letters, referral documents, or other paperwork that shows you followed the proper procedures. If your doctor recommended the treatment, get them to document why alternative treatments wouldn’t have worked or weren’t appropriate.
File Your Internal Appeal First
Most insurance plans require you to go through an internal appeals process before taking any other action. This means the insurance company reviews its own decision—which might sound pointless, but it’s a necessary step.
Submit your appeal in writing and include all supporting documentation. Be specific about why you believe the denial was incorrect. Reference your policy language, include medical evidence, and explain how the service meets coverage criteria.
Car accident lawyers recommend keeping copies of everything you send. Send your appeal via certified mail so you have proof of when it was received. Follow up with a phone call to confirm they received your appeal and ask for a timeline for their decision.
Consider An External Review
If your internal appeal is denied, you typically have the right to request an external review by an independent third party. This reviewer looks at your case fresh and isn’t employed by your insurance company.
External reviews are especially important for denials based on medical necessity. An independent medical specialist can evaluate whether the insurer’s decision was reasonable based on current medical standards.
The external reviewer’s decision is usually binding on the insurance company. If they overturn the denial, your insurer must pay the claim.
Get Help If You Need It
Appealing a claim denial can feel overwhelming, especially when you’re already dealing with an injury or illness. Consider enlisting help from your doctor’s office—they often have staff members who handle insurance appeals and know the process well.
Your state’s insurance department may also offer assistance. Many have consumer services divisions that help people understand their rights and navigate disputes with insurance companies.
If the amount in question is substantial, consulting with a qualified attorney who understands insurance law might be worth considering. Some attorneys offer free consultations to evaluate whether you have a strong case.
The Bottom Line
Insurance claim denials are frustrating, but they’re not necessarily final. With persistence and proper documentation, many denials can be overturned. Don’t let the complexity of the appeals process discourage you from fighting for coverage you’re entitled to receive.
The key is acting quickly, keeping detailed records, and not being afraid to escalate your appeal if the initial review doesn’t go your way. Your policy is a contract, and you have every right to hold your insurance company to their end of the bargain.
