Answers
My claim was denied
A letter says insurance will not pay. A denial is a decision, not a verdict, and most of them can be appealed. The letter itself tells you how and by when.
Answers
- My claim was deniedWhy was my claim denied? How to read the letter
The letter holds a reason code. Find it, ask what it means in plain words, and you will know whether this is a paperwork fix or an appeal.
- My claim was deniedHow long do I have to appeal?
For most private health plans, about 180 days from the denial letter. Medicare deadlines are shorter. Your exact deadline is printed on the letter.
- My claim was deniedDo I need my plan's OK before this test or surgery?
Your plan's OK before certain care. Not a promise to pay, but without it the plan may not pay. Confirm it yourself before the appointment.
- My claim was deniedHow do I write an appeal letter?
One page: the facts, what you want, why the denial reason does not apply, and the proof attached. Send it the way the letter says and keep a copy.
- My claim was deniedHow do I get a letter of medical necessity?
A doctor's letter that explains why you need this care, in the plan's own terms. Give the office the denial letter so it can answer the exact reason.
- My claim was deniedMy appeal was turned down — is there another step?
Usually yes. Private plans must offer an external review after a final denial, and Medicare has five levels. The letter names the next step and the deadline.
- My claim was deniedMy medication was denied at the pharmacy — what now?
Get the rejection reason from the pharmacist. It is often a prior authorization or step-therapy rule, and the fix usually starts with the prescriber's office.
- My claim was deniedThe ER visit was denied as "not an emergency" — what now?
You can appeal. Emergency care is judged by what a reasonable person would think at the time, not by the diagnosis. Your arrival symptoms are the evidence.
- My claim was deniedThe plan said "not medically necessary." What now?
A reviewer decided the care did not meet the plan's rule for your diagnosis. Ask for that rule and have your doctor answer it, point by point.
- My claim was deniedHow do I complain to my state insurance department?
Every state insurance department takes health plan complaints. File with your letters and a short timeline; the department asks the plan to respond.
- My claim was deniedCan someone outside my plan look at my denial?
An independent reviewer takes a second look at a final denial. Ask for one after internal appeals end; the plan must follow the result.