My claim was denied
Why was my claim denied? How to read the letter
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Your denial letter names a reason code and the plan rule behind it. Find that code and ask the plan what it means in plain words. Then you know if this is a paperwork fix or an appeal.
What to do
- Find the denial reason and its code on the letter or on the Explanation of Benefits (the statement your plan sends after it processes a claim).
- Call the plan and ask what the code means and what documentation would change the answer.
- Sort the reason into one of three groups: paperwork (wrong code, missing information, sent to the wrong plan), coverage (the plan says it does not cover this), or medical necessity (the plan says you did not need it).
- Write down the appeal deadline printed on the letter and put it on your calendar today.
- Ask the provider's billing office to correct and resend the claim if the reason is paperwork, before you file an appeal.
What to say
Can you tell me the exact reason code on this denial and what it means? And what documentation would you need to approve this?
Ask for the person's name and a reference number for the call before you hang up.
What to watch out for
This is a sensitive stepSmall details here can change the outcome, and some mistakes are hard to undo. We highly recommend a free 15-minute call with us before you decide.
Paying the bill or letting the deadline pass because the letter looked final. A denial is the start of a process, not the end of it, and the deadline is printed on the letter.
Better done together
We’re here to help
Denial letters are written in the plan's language, not yours. We read the letter with you, find the reason code and the rule behind it, and work out together which kind of denial it is and what the plan needs to say yes.
Do it with us once, and the next letter will make sense on your own.
Every situation is different, and these are sensitive moments, so we look at yours with care. We often see what others miss, and we never take commissions from insurance companies: the only thing we are working for is what is right for you.
Free · 15 minutes · No pressure
The rule behind it
When a plan denies a claim, it must tell you in writing why. The notice must give the specific reason, point to the plan rule it relied on, and explain how to appeal and the time limits (29 CFR 2560.503-1(g)). Under the Affordable Care Act rule (45 CFR 147.136), the notice must also include the denial code and what it means, and say that you can ask for the diagnosis and treatment codes. The denial is measured against your plan document, often called the Evidence of Coverage or Summary Plan Description. Most plans give you at least 180 days from the denial to file an internal appeal, and your letter shows the exact date.
Sources
- HealthCare.gov — Internal appeals
- 29 CFR 2560.503-1 — what a denial notice must say
- 45 CFR 147.136 — ACA notice requirements
- U.S. Department of Labor — Plan information (Summary Plan Description)
Amanda Alcodia
Education, not medical, legal or insurance advice.
Useful next steps
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