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Insurers deny claims due to out-of-network care, incomplete paperwork or coverage disputes. You're left with unexpected bills for care you thought was covered.
Fight denied claims through appeals. Identify why the claim was rejected, collect supporting documents and file internal and external reviews to challenge the decision.
Review the Explanation of Benefits (EOB) or denial letter to know why your claim was denied. Terms like "medically necessary" or "out-of-network" are key clues.
Gather documents like the EOB, original claim, medical bills and supporting medical records before starting your appeal.
File an internal appeal within the insurer’s deadline, between 30 and 180 days.
If an internal appeal doesn’t overturn the denial, file an external review with a third party or seek help from a patient advocate.
Look at why your health insurance claim was denied. Gather supporting documents, file an internal appeal and pursue an external review.
Figure out why your insurer denied your claim. Check your Explanation of Benefits (EOB) or denial letter for specific terms. Call your insurer and ask for an explanation. Common reasons insurers deny claims include:
Insurers reject claims if they determine the treatment doesn't meet their medical necessity criteria. This means they see the procedure as optional or believe there are more cost-effective alternatives.
Receiving care from a provider not listed in your plan’s network often results in claim rejections. Many policies limit coverage to in-network providers, even for necessary treatments.
Policies have financial caps on specific treatments. If your care exceeds these limits, the insurer denies further payments, leaving you responsible for the remaining costs.
Claims lacking the required paperwork, such as medical records or supporting notes, are denied. Submitting all required documents helps the insurer assess the claim properly.
Every insurance plan has exclusions. If your treatment falls outside what's covered (like certain alternative therapies or elective procedures) your claim gets denied.
Collect:
Keep records organized by category, whether physical folders or digital files. Log every insurer conversation: the date, the representative's name and what you discussed. Set reminders for appeal deadlines so nothing slips through.
An internal appeal asks your insurer to take another look at its decision. You can submit new evidence, correct misunderstandings or challenge the denial based on your policy's terms.
You have 30 to 180 days after receiving your denial notice to file an internal appeal. Here's how to file:
If delaying treatment puts your health or life at risk, call your insurer and request an expedited appeal. Tell them why the situation is urgent and get a supporting statement from your health care provider. Insurers must respond within 72 hours, so log every conversation and follow up if you don't hear back.
Insurers must respond to appeals within set timeframes: 30 days for pending treatments, 60 days for completed treatments and 72 hours for urgent cases. Mark these dates on your calendar so you know when to expect a response.
If you don't hear back by the deadline, reach out to your insurer by phone or email. Log all communications throughout the process, including dates, representative names and any instructions you receive.
An external review is an independent evaluation of your denied claim by a third party that can overturn your insurer's decision based on policy details and medical evidence. You can request one if your internal appeal is denied or your claim involves medical necessity determinations or policy exclusions. Check your insurer's guidelines to confirm eligibility.
If you qualify, contact the assigned independent reviewer, complete all required forms and submit supporting evidence: updated medical records, provider statements and any other relevant documents. Keep copies of everything you send and note the dates. Standard external reviews take about 45 days.
A denied appeal leaves you with several options: consulting a lawyer, filing a complaint with state regulators or pursuing mediation.
If all appeals fail, consult a lawyer specializing in health insurance law. These professionals review your case in detail, determine if the insurer violated laws and guide you through potential actions like filing a lawsuit. This step works best when you suspect that your rights have been violated or if there are complexities in your case requiring formal legal action.
Submitting a formal complaint to your state's insurance department can lead to an investigation into your insurer's conduct. Each state has an insurance regulator, with complaint procedures available on their website. Make sure to provide complete documentation, including denial letters, policy details and a summary of your appeal efforts, to support your case.
Patient advocates specialize in insurance appeals and can help gather evidence, communicate with your insurer and navigate the appeals process. Contact an advocate if the process feels overwhelming or you're unsure how to proceed.
A neutral mediator can help you and the insurer negotiate a settlement out of court. If mediation fails, litigation is your final option. Lawsuits usually take one to three years and require extensive documentation and legal fees.
What you need to know about fighting a health insurance denial:
Success rates vary, but research shows over 80% of prior authorization appeals end with insurers partially or fully reversing their denials. Your odds depend on the denial reason, the strength of your evidence and how thoroughly you build your case.
Start with an internal appeal, then file an external review or submit additional information that addresses the denial reason. If those options fall short, consult a lawyer, file a complaint with state regulators or try mediation.
Most insurers give you 30 to 180 days from the denial notice to file an internal appeal. Check your insurer's deadline and move quickly.
Call your insurer right away and ask for an extension. Some allow extra time for valid reasons. You can also file a complaint with state regulators or consult a lawyer about other options.
Yes, and new evidence or additional documentation strengthens your case for a second attempt. Check your insurer's guidelines for the number of appeals allowed and whether an external review is available after multiple denials.
These MoneyGeek resources cover comparing health insurance, choosing the right plan, reducing medical bills and managing medical debt.
About Nathan Paulus
Nathan Paulus is Head of Content and SEO at MoneyGeek, where he leads content strategy, produces original data research, and oversees the site's coverage across insurance, consumer costs, transportation safety, housing, public policy, and personal finance. He also performs expert reviews of published studies, assessing methodology, source quality, and factual accuracy before content reaches readers.
Research and Analysis
In nearly six years at MoneyGeek, Paulus has published more than 100 original studies and explanatory guides. His data work ranges from insurance rate analyses to broader consumer and public policy research. On the insurance side, his studies include 50-state comparisons of health care outcomes, costs, and access; an analysis of how uninsured rates track with state Medicaid expansion decisions and electoral patterns; full-coverage auto rate analyses across major insurers in all 50 states; and an examination of how premium trends relate to industry underwriting losses using combined ratio data from Fitch Ratings, AM Best, and Bureau of Labor Statistics CPI figures. Beyond insurance, his research covers vehicle pricing trends across the U.S. new car market, summer traffic fatality rates by state, homeowner underinsurance ratios using mortgage and policy data, and housing affordability across all 50 states.
His research has been cited by Bloomberg, the Los Angeles Times, Forbes, Fast Company, the San Francisco Chronicle, USA Today, and NBC Los Angeles, and referenced by leading universities including Harvard, MIT, Stanford, and Yale.
Career
Growing up, Paulus developed an early interest in personal finance through his grandmother, who emphasized saving over earning as the foundation of financial stability. That perspective shapes how he approaches making financial data accessible to general audiences.
Paulus joined MoneyGeek in July 2020 as Director of Content Marketing, leading the content team and directing data journalism production across insurance and personal finance verticals. He was promoted to Head of Marketing and Communications in December 2023, taking on broader responsibility for digital PR and communications strategy. He has held his current role as Head of Content and SEO since January 2025. Before MoneyGeek, he served as Director of Content Marketing and SEO at Ventrix Advertising, where he was part of a small team that built two content sites from the ground up, contributed to link-building programs that secured more than 1,500 unique referring domains within a year, and helped manage a marketing team of more than 20 people. Earlier, he spent two and a half years at ABUV Media progressing from Marketing Research Analyst to Senior Marketing Tactics Analyst, building his foundation in audience research, content strategy, and SEO.
