My Insurance Claim Was Denied — What Do I Do Right Now?

You opened a letter — or a patient portal notification, or maybe even a phone call — and the words hit like a punch to the stomach: your claim has been denied.

You paid your premiums. You went through the right channels. You thought you were covered. And now an insurance company is telling you no.

First: take a breath. This is devastating, and your anger and fear are completely valid. But here's what you need to know right now — a denial is not the end. It is the beginning of a fight you can win.

Studies consistently show that 40% to 83% of insurance appeals are successful when patients follow the right process. Most people never appeal — and that's exactly what insurance companies count on. You're already ahead of the curve just by reading this.

Why Claims Get Denied (It's Often Not What You Think)

Insurance companies deny claims for dozens of reasons, and many of them have nothing to do with whether your treatment was actually necessary. Common denial reasons include:

• "Not medically necessary" — the insurer decided (without examining you) that your doctor's recommendation isn't required
• Prior Authorization Denied: How to Appeal" class="auto-link">Prior authorization missing — a pre-approval step wasn't completed, sometimes due to administrative error
• Out-of-network provider — you saw someone your plan doesn't fully cover
• Coding errors — a billing code was entered incorrectly and triggered an automatic rejection
• Missed deadlines — the claim was filed too late
• Experimental or investigational — the insurer classified your treatment as unproven

Here's the critical insight: many of these are fixable. A coding error can be corrected. A missing prior authorization can sometimes be obtained retroactively. "Medical necessity" denials can be overturned with the right documentation.

Your Immediate Action Plan (Next 72 Hours)

1. Don't panic — read everything carefully

Get the denial letter and read every word. Look for:

• The specific reason for the denial (required by law to be included)
• Your appeal deadline — this is usually 30 to 180 days depending on your plan
• Instructions for how to file an internal appeal
• Contact information for your insurer

If you don't have the denial in writing, call your insurer and request it immediately. Keep notes on every conversation — date, time, name of representative.

2. Call your doctor's office

Your provider is your most important ally. Tell them about the denial and ask them to:

• Review the denial reason
• Write a letter of medical necessity supporting your case
• Check whether any coding errors or authorization issues may have caused the denial
• Provide clinical notes, test results, or peer-reviewed research supporting your treatment

Doctors deal with insurance denials constantly. A good practice will know exactly what documentation is needed.

3. Request your complete claim file

Under federal law (ERISA for employer-sponsored plans, ACA for marketplace plans), you have the right to request all documents related to your claim — including the insurer's internal guidelines used to make the denial decision. This information is vital for building your appeal.

Call member services and ask for: "all documents, records, and guidelines relevant to my claim denial." They are legally required to provide this.

4. Understand your timeline

Do not miss your appeal deadline. This is the single most important thing. Once the deadline passes, you may lose your right to appeal entirely.

• Most employer-sponsored plans (ERISA): 180 days from denial notice
• Marketplace/ACA plans: at least 30 days (often more)
• Medicare: 120 days for standard appeal
• Medicaid: varies by state, but usually 90 days

Write the deadline on your calendar today.

5. File your internal appeal

Your first step is filing a formal internal appeal with your insurance company. This is a written request asking them to reconsider the denial. Include:

• A clear statement that you are appealing and why
• Your doctor's letter of medical necessity
• Relevant medical records
• Any peer-reviewed literature supporting your treatment
• A personal statement explaining the impact of the denial on your health

Be specific. Be factual. Reference the insurer's own clinical criteria if you can get them.

What Comes After the Internal Appeal

If your internal appeal is denied, you're not done yet. Under the ACA, most plans must offer an External Independent Review: Complete Guide" class="auto-link">external review — an independent review by a third party with no financial interest in the outcome. External reviews overturn insurer decisions approximately 40% of the time.

You can also file complaints with your state's insurance commissioner, contact a patient advocate, or consult an attorney who specializes in insurance bad faith claims.

You Are Not Alone in This

Insurance denials happen millions of times every year. And millions of those denials are successfully appealed. The system is designed to be confusing and exhausting — but it can be navigated.

Fight Back With ClaimBack

ClaimBack exists for exactly this moment. Our platform helps you build a compelling, professionally structured appeal — the kind that actually gets read and acted on. Don't face this alone.

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

The insurer said no. Make them say yes.

Related Reading

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