Health Insurance Claim Denied? How to Appeal

Getting a health insurance claim denied feels like a punch to the gut. You paid your premiums, followed the rules, and now you're stuck with a bill you thought was covered. You're not alone in this frustration, and understanding the health insurance claim appeal process can save you thousands of dollars.

Here's the encouraging part: 44% of internal appeals succeed in overturning denials, yet less than 1% of people even try. When you know how to navigate fighting insurance claim denial situations, the odds shift heavily in your favor.

Why Insurance Companies Reject Claims

Insurance claim rejection happens for many reasons, and not all of them involve bad faith. Understanding these patterns helps you avoid denials before they happen.

Administrative and Paperwork Errors

Administrative issues cause the majority of denials. According to KFF's analysis of marketplace health insurance data, approximately 77% of denials stem from paperwork problems or plan design rather than medical judgment. Common culprits include missing forms, incorrect patient information, billing code errors, and claims sent to the wrong insurer. The good news? Most of these can be fixed with a quick phone call to your insurance company.

Missing Prior Authorization

Many plans require approval before certain treatments, procedures, or imaging tests. Skip this step, and your insurer can deny the claim even when the care was medically necessary. Prior authorization requirements vary by plan, so always check with your insurer before scheduling non-emergency procedures.

Services Your Plan Doesn't Cover

Not every medical service falls under every plan. Common exclusions include experimental treatments, cosmetic procedures, and out-of-network services. Reading your Summary of Benefits Coverage helps you understand what's covered before you receive care, preventing surprise denials down the road.

Medical Necessity Disputes

Sometimes, insurers determine a treatment wasn't medically necessary, even when your doctor recommended it. While this plays a smaller role than administrative issues, it's one of the harder denials to overturn. Your doctor needs to provide documentation explaining why the service was essential for your health.

How to Win Your Appeal

When your health insurance claim denial notice arrives, don't accept it as final. The appeals process exists to protect you, and it works more often than you'd think.

Read Your Denial Letter Carefully

Start by understanding exactly why your claim was rejected. The denial letter must explain the specific reason. Sometimes a simple billing code error can be corrected with one phone call to your provider's billing department.

Build Your Case With Documentation

Before filing an appeal, gather your insurance policy, denial letter, medical records, receipts, and a letter from your doctor explaining medical necessity. Strong documentation significantly improves your chances. Ask your healthcare provider to write a detailed explanation of why the treatment was essential for your condition.

File Your Internal Appeal

You have 180 days from the denial date to file an internal appeal with your insurance company. Keep your appeal letter brief and specific. Explain why the claim should be covered and attach all supporting documents. Decision timelines vary: 72 hours for urgent care situations, 30 days for pre-service appeals, and 60 days for post-service appeals.

Request an External Review When Needed

If your internal appeal fails, you can request an external review where an independent third party examines your case. You must file within 60 days of the internal appeal decision. External reviews overturn denials about 27% of the time, giving you another real shot at coverage.

Smart Ways to Prevent Denials

While you can't eliminate all denials, you can reduce your risk significantly by taking a few proactive steps.

• Verify coverage before treatment by calling your insurer to confirm a service is covered under your plan
• Get prior authorization when required, and ask your doctor's office to handle the paperwork
• Stay in network whenever possible, since out-of-network claims face denial rates nearly double those of in-network care
• Double-check all paperwork for accuracy before submitting

Understanding your health benefits as an employee puts you in a stronger position to catch potential problems before they become denials.

How Venteur Puts You in Control

At Venteur, we believe everyone deserves health insurance they actually understand and can use. Our ICHRA platform gives you access to flexible, individualized plans where you choose coverage that fits your specific needs. Instead of settling for a one-size-fits-all group policy, you get the most personalized plan-buying experience available.

When you select your own individual health plan, you gain deeper familiarity with your coverage details. That knowledge makes it easier to verify benefits before treatment and avoid the common pitfalls that lead to insurance claim rejection. Plus, your coverage stays with you wherever your career takes you.

Take Action on Every Denial

Fighting insurance claim denial situations might feel overwhelming, but the numbers are on your side. With 44% of internal appeals succeeding and external reviews providing another path forward, giving up means leaving money on the table.

Start by reading your denial letter carefully, gathering your documentation, and filing that appeal. Your health and your wallet are worth the effort.