How to Appeal a Health Insurance Denial

When your health insurance denies coverage for a medication, procedure, test, hospital admission, or other healthcare service, you have legal rights to challenge that decision through a formal appeals process. Insurance denials are common — studies suggest that anywhere from 5–17% of claims are initially denied — and importantly, a substantial proportion of appeals are successful. Understanding the appeals process and how to navigate it effectively can result in coverage for care your physician has determined you need.

Understanding Your Denial

When an insurer denies a claim or pre-authorization request, they are required by law to provide a written explanation (called an Explanation of Benefits or denial letter) that includes:

• The specific reason for denial
• The evidence, guidelines, or criteria used to make the decision
• Information about your right to appeal and the deadlines for doing so
• Instructions for how to submit an appeal

Read this letter carefully. The specific reason for denial matters — a denial for "not medically necessary" is challenged differently than a denial for "not covered benefit" or "out of network."