How to Handle Insurance Denials and Limits

Finding out that your health insurance company has denied a claim can be frustrating and complicated. Understanding what an insurance denial is and what you can do about it may be helpful.

Your insurance company must provide you with the following pieces of information if it is denying a claim:¹

• The specific reason why your claim was denied
• Information on your right to file an appeal
• Detailed instructions on how to file an appeal and key deadlines
• Contact information for a customer service representative who can assist you

All the above information usually comes in a letter or document titled “Explanation of Benefits.”²

What is an insurance denial?

An insurance denial is when your health insurance company will no longer cover the costs of medicine or service. If you cannot get the medicine or treatment you need without paying the full cost, it can be scary.

An insurance company may deny a claim for a variety of reasons, including:^2,3

• The current treatment you are on or medicine you are taking is not necessary or the right treatment.
• You are receiving treatment considered “experimental.”
• The doctor you saw is out of your insurance company’s network.
• Your doctor did not approve a particular medicine or specialist.
• Your coverage has lapsed and you are no longer enrolled with your insurance company’s plan.
• You missed several payments.
• There were errors made on your claim like typos or misspellings.
• You have reached the financial limit your insurance will cover.

It is important to review any denials you receive and address them right away. If you choose, you can file an appeal.²

What is an appeal, and how does it work?

If your insurance company denies your claim, you can file an appeal. An appeal is when you ask your insurance company to reconsider its decision to deny covering a medicine or treatment. It can take time to complete.²

If you decide to file an appeal, you need to act as soon as possible. Your insurance company provides a time frame in which a denial can be appealed. If you do not file an appeal within this time frame, it may be denied because it did not meet the deadline set by the insurance company.²

Your insurance documents or the insurance company’s website may explain the insurance appeal process. Many states have a consumer assistance program that can help you with the appeals process. Note that these are different from state to state.²

If your insurance plan is through your employer, contact your human resources department. They should be able to point you in the right direction to find the information you need about making an appeal.²

Your primary care doctor also should be able to assist you in filing the appeal and gathering the different documents you need.²

Once you decide to file an appeal, try to stay organized. Keep related documents and insurance company contacts in one place.¹

An appeals process may not happen overnight, and you may have to file several times. Sometimes, appeals are approved right away. Other times, you may have to wait or go through the appeals process many times.²

You are not alone

Dealing with insurance denials may seem like a daunting task. But resources are available to help you. Many states have assistance programs that can answer questions and advocate on your behalf. Each state also has an insurance commissioner's office with staff who can help you.^2,3