Fight back on bills

What to Do When Your Claim Is Denied

A denial is the start of a process, not the end of one. The deadlines, the two levels of appeal, and what actually changes an insurer's mind.

Current as of August 23, 2026 Fight back on bills

Most denied claims are never appealed. That is the single most important fact about denials, because a meaningful share of appeals succeed - and the ones that succeed are frequently the ones where nothing was clinically in dispute at all.

You have a legal right to a full and fair review, at two levels, on a defined timetable.

First: find out what kind of denial this is

The reason printed on the notice determines everything about how you respond. Broadly, denials sort into four types.

Clerical. Wrong date of birth, wrong member ID, wrong provider number, a typo in a code. Nothing about your coverage is in dispute; the claim simply does not match the record. These are usually fixed with a phone call to the provider’s billing office asking them to correct and resubmit. No formal appeal needed.

Coding. The diagnosis code submitted does not support the procedure code, or the wrong procedure code was used. This looks like a coverage denial and reads like one - often as “not medically necessary” - but the fix is at the provider’s billing office, not the insurer’s appeals department. Always check this before you write an appeal about medical necessity.

Administrative. Prior authorization was not obtained. The claim was filed after the deadline. Coordination of benefits information was never provided. Some of these are your problem to fix; several are the provider’s. Missed prior authorization and missed timely filing are usually the provider’s, and the resulting balance often should not be passed to you.

Substantive coverage. The plan says the service is excluded, experimental, or does not meet its medical necessity criteria. This is the real appeal, and it is the one where documentation from your clinician matters most.

Calling to ask “what specifically caused this denial, and what would resolve it?” costs you fifteen minutes and frequently ends the matter. Write down the date, the representative’s name, and the reference number.

The deadlines

Step	Your deadline	Their deadline
Internal appeal	At least 180 days from the denial notice	30 days for pre-service care, 60 days post-service
Expedited internal appeal	Any time for urgent situations	As fast as the urgency requires
External review	Generally within 4 months of the final internal denial	45 days standard
Expedited external review	Urgent situations	72 hours or less

The 180-day window is the one to protect. It is generous, and it is also absolute - miss it and your strongest argument may not be heard at all. File something within the window even if your documentation is incomplete; you can supplement afterward.

If the situation is urgent - meaning delay would seriously jeopardize your life or your ability to regain maximum function - you can request an expedited review and, in urgent cases, pursue internal and external review at the same time rather than waiting for one to finish.

What to ask the plan for, and why

When you file the internal appeal, request in writing:

A free copy of all documents, records, and criteria used in the original decision - including any internal rule, guideline, protocol, or clinical standard relied on. You are entitled to this, and you often have to ask twice.
Review by someone not involved in the original decision and not that person’s subordinate. That reviewer must give no deference to the first decision.
A written explanation of the outcome and, if upheld, your external review rights.

The first item is the one that changes cases. Insurers deny against written criteria. Once you can see the criteria, the appeal stops being an argument about whether the care was appropriate and becomes a demonstration that the documentation meets a specific written standard - which is a much easier thing to win.

What actually persuades

A letter from your clinician tied to the plan’s own criteria. Not a general statement that the care was needed. A letter that names the criterion and explains how your record satisfies it. If you obtained the plan’s clinical guideline in step one, give it to your clinician’s office - most will write a much stronger letter when they can see the target.

Documentation of what was tried first. Many denials rest on step therapy or conservative-treatment-first rules. Dates, durations, and outcomes of earlier treatments answer that directly.

Dated evidence of network status or prior authorization. A screenshot of the plan’s directory with the date visible. An authorization reference number and the date it was issued. These end administrative denials quickly.

Brevity. One page of specific, dated, verifiable statements beats six pages of frustration. The reviewer is working through a queue.

Our internal appeal template is structured around these.

If the internal appeal fails

You get an independent one. External review sends the case to a reviewer with no relationship to your insurer, and the decision is binding on the plan. This is the part of the system that works best and is used least.

How to file depends on your plan: some states run the process for their regulated plans, and self-insured employer plans typically use a federal process. The final internal denial letter must tell you which applies to you and how to start it. If the letter does not, call and ask - that instruction is required.

Two things worth knowing

A denial is not a bill. When your plan denies a claim, the provider may bill you, but the underlying question of who owes what is still open. Do not pay a balance created by a denial you are actively appealing, and tell the provider’s billing office in writing that an appeal is pending.

Your state insurance department is a real option. If a plan is missing its own deadlines, refusing to send the criteria, or giving you inconsistent answers, a complaint to the state regulator often produces movement that months of phone calls did not. For employer self-insured plans, the federal Employee Benefits Security Administration handles the equivalent role.

If the appeal ultimately fails and the balance stands, the bill becomes a different problem - check it for errors, then look at financial assistance and negotiation.

Sources

Figures and rules on this page are current as of August 23, 2026. Dollar limits and deadlines change - check the linked source before you rely on a number.

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