How to Appeal a Denied Health Insurance Claim

A denied insurance claim is not necessarily the final word. You have the right to appeal — and many denials are overturned on appeal. Here's how the process works.

Why Claims Get Denied

Common reasons for claim denials include:

• The service was deemed not medically necessary by the carrier
• The provider was out-of-network
• Prior authorization was required but not obtained
• The claim was filed incorrectly or with missing information
• The service is excluded under your plan

Your Right to Appeal

Under the ACA, all health insurance plans must provide an internal appeals process. You have the right to request a full review of any denied claim. The denial notice you receive must include the reason for denial and instructions for filing an appeal.

The Appeals Process

• Step 1 — Internal appeal: Submit a written appeal to your insurance carrier within the timeframe specified in your denial notice (typically 180 days). Include supporting documentation from your provider.
• Step 2 — External review: If your internal appeal is denied, you have the right to request an independent external review. An independent organization reviews the decision — your carrier must abide by the result.

Tips for a Stronger Appeal

• Get a letter of medical necessity from your doctor
• Reference specific plan language that supports coverage
• Keep copies of everything you submit
• Meet all deadlines — missed deadlines can forfeit your right to appeal

BenZen helps clients navigate coverage issues across GA, FL, MD, VA, PA, and more. If you need guidance on an appeal, reach out directly.