How to Get Your Insurance Company to Pay a Denied Claim

You're not interested in theory. You want to know: what specific actions will get your insurance company to actually pay this denied claim?

Good. Let's get to it.

The process has steps, it has timelines, and it requires documentation. But it works. Studies consistently show that 40–83% of properly filed insurance appeals succeed. Your job is to be one of the patients who wins.

Here's exactly what to do.

Phase 1: Understand What You're Fighting (24–48 Hours)

Before you do anything else, you need to understand the denial.

Get the denial letter. If you don't have it in writing, call your insurer's member services and request the formal denial notice. This document is legally required to include:

• The specific reason for denial
• The clinical criteria or plan provisions used
• Your appeal rights and deadlines

Identify the denial type. Common denial types require different strategies:

• Not medically necessary — you'll need clinical documentation from your doctor
• Prior Authorization Denied: How to Appeal" class="auto-link">Prior authorization missing — you may be able to resolve this quickly with your doctor's office
• Out-of-network — you need to know if No Surprises Act or network adequacy arguments apply
• Experimental/investigational — you'll need clinical guidelines and literature
• Coding error — your doctor's billing team may be able to correct and resubmit
• Coverage exclusion — you need to understand whether the exclusion actually applies

Note your appeal deadline. Write it on your calendar, set a phone reminder, tell someone else. Missing the deadline forfeitures your right to appeal.

Phase 2: Build Your Case (3–10 Days)

This is where appeals are won or lost. A weak documentation package loses. A strong one wins. Take the time to do this right.

Contact your doctor that same day

Call your treating physician or specialist and tell them: "My insurance denied my claim and I need to appeal. Can you write a letter of medical necessity and provide supporting documentation?"

Good doctors' offices deal with this constantly and can often turn around documentation quickly. What you need from them:

• A letter of medical necessity — detailed, specific, citing your diagnosis, the clinical basis for treatment, alternatives considered and rejected, and consequences of denial
• Relevant medical records supporting your case
• For "experimental" denials: clinical guidelines and published literature supporting the treatment

Request the insurer's clinical criteria

Call member services and ask for "all clinical guidelines and criteria used in reviewing and denying my claim." Use these to tailor your appeal — show exactly how your case meets their stated criteria.

Gather your own evidence

• Relevant medical records (keep copies of everything)
• Any peer-reviewed literature your doctor identifies as supporting your treatment
• Documentation of prior related treatment that establishes clinical history
• Your personal statement (written by you, describing your condition and the impact of the denial)

Phase 3: File Your Formal Internal Appeal

With your documentation package ready, submit your formal internal appeal.

What to include:

1. A cover letter clearly stating you are appealing denial [CLAIM NUMBER] dated [DATE], and requesting reversal
2. Your doctor's letter of medical necessity
3. Supporting medical records
4. Clinical guidelines cited in your favor
5. Your personal statement
6. A list of all attached documents

How to submit:

• Send via certified mail with return receipt (you need proof of delivery and date)
• Or use the insurer's online appeal portal if available (keep screenshots/confirmations)
• Keep a complete copy of everything you submit

Response timelines:

• Prior authorization / pre-service appeals: insurer must respond within 30 days
• Post-service appeals: insurer must respond within 60 days
• Expedited urgent appeals: 72 hours

If your situation is medically urgent — delaying the appeal could harm your health — request expedited review. Your doctor must certify the urgency.

Phase 4: If Internal Appeal Is Denied — External Independent Review: Complete Guide" class="auto-link">External Review

Your insurance company denied your internal appeal. You have not exhausted your options.

Request an external independent review. This is a review by a neutral third party — an IROs) Explained" class="auto-link">Independent Review Organization (IRO) — with no financial relationship to your insurer. Their decision is binding on the insurer.

External reviews succeed roughly 40% of the time nationally. For well-documented cases, rates are higher.

File within:

• 60 days of internal appeal denial for ACA plans
• 4 months (122 days) for ERISA employer plans

Include the same documentation package you used for your internal appeal, updated with any new evidence.

Phase 5: Regulatory Escalation

While external review is your most direct path to reversal, regulatory pressure is a parallel strategy:

State insurance commissioner complaint: File a formal complaint with your state's insurance regulatory agency. This creates a regulatory record, may trigger an investigation, and often prompts insurers to reconsider denied claims to avoid regulatory scrutiny. Many state commissioners have consumer assistance units that actively advocate for claimants.

Department of Labor complaint (for ERISA employer plans): File with the Employee Benefits Security Administration (EBSA). EBSA has authority to investigate improper claim denials by employer-sponsored plans.

CMS complaint (for ACA Marketplace plans): The Centers for Medicare & Medicaid Services oversees marketplace plan compliance and takes consumer complaints seriously.

Phase 6: Legal Options

For high-value denials or patterns of improper conduct:

ERISA litigation: If your employer plan improperly denied a claim, you have the right to sue in federal court under ERISA Section 502(a). The standard for ERISA suits depends on the plan terms, but wrongful ERISA denials are litigated successfully.

State bad faith claims: For non-ERISA plans (individual market, some state government plans), your state's insurance bad faith law may allow you to sue for damages beyond the original claim — including punitive damages and attorney's fees — if the insurer denied your claim without a reasonable basis.

Attorney consultation: Many insurance attorneys consult for free and work on contingency. If your claim is large and the denial appears improper, a consultation costs you nothing.

The Bottom Line

Insurance companies deny claims knowing that most patients give up. The appeal process is the mechanism that forces them to reconsider — and it works when you use it correctly.

Every step in this process has been successfully used by patients to overturn denials and get their claims paid. The documentation takes effort. The timelines matter. But the result is your healthcare being paid for as it should be.

Fight Back With ClaimBack

ClaimBack gives you the platform to organize your documentation, structure your appeal, and present the strongest possible case to your insurer.

Start your appeal at https://claimback.app/appeal

You paid for coverage. Make them honor it.

Related Reading

• How to Write an Insurance Appeal Letter
• Internal vs. External Insurance Appeal: Which Should You File?
• Common Reasons Insurance Claims Are Denied