Getting a denial letter from your health insurance company can feel frustrating and unfair — especially when your doctor ordered the care. But here's what most people don't know:

You have the legal right to appeal — and win.

Thanks to expanded patient protections under the Affordable Care Act, insurance companies must give you the chance to challenge their decision. In fact, many denials are overturned once patients take action.

This guide walks you through why claims get denied, how to understand your denial letter, and what steps to take to appeal effectively.

Why Was My Insurance Claim Denied?

Health insurance companies deny claims or coverage requests for several reasons — some valid, some questionable. Here are the most common reasons for denial:

  • The service was not considered medically necessary
  • The treatment setting was deemed inappropriate (e.g., inpatient vs. outpatient)
  • You were deemed ineligible for that specific benefit under your plan
  • The treatment is considered experimental or investigational
  • The claim was submitted late or incomplete

Before reacting, remember: a denial is not final. It's the start of a process you can challenge.

Step 1: Review Your Denial Letter Carefully

When your insurer denies a claim or pre-authorization request, they must send you a written denial notice. This letter is essential — it holds the details you need to appeal.

It should include:

  • ✅ The reason for denial
  • 📄 Your right to file an appeal
  • 📝 Instructions for submitting your appeal
  • 📅 Deadlines for filing
  • ☎️ Information about any Consumer Assistance Programs in your state

If anything is unclear, call your insurer's member services and ask for a detailed explanation.

Step 2: Understand Your Appeal Rights

You can challenge a denial at multiple levels:

🧩 Internal Appeal

This is the first step. You're asking the insurance company to reconsider their decision. You'll submit supporting documents, like:

  • A letter from your doctor explaining why the service is medically necessary
  • Test results or medical records
  • A copy of the denial notice

⚖️ External Review

If your internal appeal is denied, you can request an independent review by a third party. This reviewer is not connected to your insurer and has the power to overturn their decision.

🛡️ Important: Your health plan cannot cancel your coverage or increase your premium because you file an appeal. You're protected by federal law.

Step 3: Gather Documentation for Your Appeal

The more organized and complete your appeal, the stronger your case. Here's what to include:

  • Your denial letter
  • Your insurance ID number and claim number
  • A statement from your doctor explaining the necessity of treatment
  • Supporting documents like test results, treatment history, or medical studies
  • Any prior authorization documents, if applicable

Keep copies of everything you send.

Step 4: Don't Let the Bill Go to Collections

If your denied claim is tied to a service you've already received and billed for, be proactive. Contact your provider's billing office and explain that you're appealing the insurance decision.

📝 Ask them to hold the bill and not send it to collections during the appeal process.

Need help negotiating during this time? Check out resources like "Negotiating Medical Costs" from trusted advocacy groups.

Step 5: Get Help from a Consumer Assistance Program

Many states have Consumer Assistance Programs (CAPs) that can:

  • Help you understand your denial
  • Guide you through the appeal process
  • Communicate with your insurance company on your behalf

Check healthcare.gov or your state's department of insurance to see what's available in your area.

Final Tip: You Don't Have to Take No for an Answer

Insurance denials are common — and so are successful appeals. With the right documentation, a clear explanation from your doctor, and persistence, you can turn a "no" into a "yes."

Explore free tools like the "Don't Take No for an Answer" training series or guides like "Engaging with Insurers: Appealing a Denial" to help you feel confident in the process.