Insurance Denials

Insurance Denied My Claim — Now What?

Getting a denial from your insurance company feels like a wall. But it's actually a door — most denials are reversible. Insurance companies deny claims for a wide range of reasons, and many of those reasons are either technical errors, missing information, or fixable coding issues. Nationally, patients who appeal insurance denials win more than 40% of the time.

Here's what to do when your insurer says no.

Step 1: Understand Why It Was Denied

Before you can fight a denial, you need to understand exactly why it happened. Your insurer is required to send you an Explanation of Benefits (EOB) — a statement showing what was billed, what was paid, and why any portion was denied. Read the denial reason carefully; it's the key to your appeal.

Common denial reasons include:

• Not medically necessary — the insurer claims the service wasn't needed based on their criteria
• Prior authorization required — the provider didn't get advance approval (sometimes this is the provider's fault, not yours)
• Service not covered — the procedure isn't included in your plan
• Out-of-network provider — see our guide on out-of-network charges
• Wrong diagnosis or procedure code — a billing error that may have nothing to do with the actual care
• Duplicate claim — the insurer thinks you already submitted this claim
• Coordination of benefits issue — if you have multiple insurance plans, they may dispute which is primary
• Provider not enrolled — the provider isn't registered with your insurer properly

Step 2: Read Your Explanation of Benefits

Your EOB explains what your insurer processed. Match it against your medical bill to see if there's a discrepancy. For more help, see our guide on EOB vs. medical bill — what's the difference.

Key things to look for in the denial section:

• The specific denial code and reason description
• The service date and procedure code that was denied
• The appeal deadline (typically 90–180 days from the EOB date)
• The appeals address and process instructions

Handling Denials: DIY vs. MyClearBill

Task	Doing It Yourself	Using MyClearBill
Identify denial reason	Must read EOB + denial codes manually	Denial reason explained clearly
Spot billing errors that caused denial	Requires billing code knowledge	Detected automatically
Know if it's worth appealing	Unclear without experience	Assessed based on claim type
Write appeal letter	2–5 hours of research and writing	Generated with correct language
Know your appeal deadlines	Must read policy documents	Flagged from your EOB

Step 3: File an Internal Appeal with Your Insurer

Every insurance plan must offer an internal appeals process. This is your first formal step. Here's how to do it:

1. Gather your documents: EOB, original medical bill, any medical records or letters from your doctor supporting the claim
2. Write an appeal letter: Reference your policy number, the claim number, the denial reason, and your specific argument for why the claim should be paid
3. Include a letter of medical necessity from your doctor: If the denial was "not medically necessary," a doctor's letter explaining the clinical justification is often the most effective piece of evidence
4. Submit before the deadline: Most plans require appeals within 90–180 days of the denial notice
5. Send via certified mail and keep copies of everything

Step 4: Request an External Review

If your internal appeal is denied, you have the right to an independent external review. An independent organization — not affiliated with your insurer — reviews the denial and can overturn it. This is required under the Affordable Care Act for most health plans.

How to request it:

• Your denial letter must inform you of your right to external review and how to request it
• The external review organization is assigned by your state (most states use a system overseen by the Department of Insurance)
• External reviews are typically free to you
• You usually have 60–120 days after exhausting internal appeals to request an external review
• The reviewer's decision is binding — if they say the insurer must pay, the insurer must pay

Common Mistakes People Make When Fighting Denials

• Accepting the denial without appealing — most patients never appeal, and most who do win at least partial payment
• Missing the appeal deadline (often 90–180 days from the denial date)
• Appealing without a doctor's letter of medical necessity
• Not checking whether the denial was caused by a billing error at the provider level
• Paying the bill immediately instead of waiting for the appeal outcome
• Not requesting external review after an internal appeal is denied
• Failing to document every conversation with the insurer

What If the Denial Was for Preventive Care?

Under the Affordable Care Act, most insurance plans must cover preventive services — like annual physicals, vaccinations, and screenings — at 100%, with no cost-sharing. If you received a bill for a preventive service that should have been fully covered, that's likely a billing code error. The provider may have used a diagnosis code that reclassified your visit as a "treatment" visit rather than a "preventive" visit.

Ask the provider to correct the billing code. In many cases, this resolves the issue immediately without a formal appeal.

Urgency: Act Before the Window Closes

Every insurance denial comes with a deadline to appeal. Miss it, and you may permanently lose your right to contest the denial. The bill then becomes your full responsibility — and can be sent to collections, which damages your credit.

Check your EOB today. Find the appeal deadline. Start the process now.