Health insurance claim denied? What to do next

Start with the written reason. A denied claim does not tell you by itself whether the bill is correct, whether the service is excluded, or whether the insurer needs different information. The notice and your plan documents determine the official next step.

This guide focuses on claims for services already received under private or employer-sponsored health insurance. Medicare, Medicaid, pharmacy benefits, dental plans, and prior-authorization requests can follow different procedures.

Step 1: Make sure you are looking at a denial

An Explanation of Benefits, or EOB, explains how the insurer processed a claim; it is not a bill. Compare it with any provider bill and look for the amount denied, the reason or code, the patient responsibility, and the appeal instructions.

• Is the claim fully denied, partly denied, or applied to your deductible?
• Is the document final, or does the plan say information is still needed?
• Does the provider bill match the patient responsibility shown by the plan?
• What date appears on the denial notice?
• Where does the notice explain how and when to challenge the decision?

If the documents do not match, use our guide to check a medical bill and EOB for differences.

Step 2: Get the exact denial reason

Do not work from a vague message such as “insurance did not cover it.” Common explanations may involve eligibility, network status, an excluded benefit, missing information, coding, coordination of benefits, prior authorization, or a plan decision about medical necessity. The correct response depends on the actual reason.

“Please explain the denial in plain language, give me the claim and reference numbers, and tell me where the applicable plan rule appears in writing.”

Ask the insurer to identify the exact form, address or secure portal, deadline, and documents required for the next step. Record the date, representative’s name or identification number, and call reference number.

Step 3: Ask whether the claim needs correction or appeal

A provider may need to correct or resubmit a claim when information is missing or inaccurate. A formal appeal asks the plan to reconsider a coverage decision. These are not the same process.

Call the provider’s billing office and share only the denial reason—not assumptions about who made a mistake. Ask whether the claim information is accurate and whether the provider needs to submit records, correct information, or take another action.

“The plan gave this reason for the denial: ____. Does your office need to correct or resubmit anything, or should I follow the appeal instructions?”

Step 4: Protect the deadline

Use the deadline printed on your denial and plan documents. HealthCare.gov states that plans subject to its internal-appeal rules generally allow 180 days after the denial notice, but different coverage types and circumstances may follow different rules. Do not assume that a phone call, provider review, corrected claim, or billing discussion pauses an appeal deadline.

Ask both the plan and provider whether any other deadline is running. If time is short, follow the plan’s written instructions and consider contacting the appropriate official assistance program.

Step 5: Build the internal appeal around the stated reason

Follow the instructions for your exact plan. A useful appeal packet may include copies of the denial or EOB, the plan rule at issue, the appeal form or letter, relevant provider information, and a short timeline. Ask the treating professional whether clinical documentation or a supporting statement is appropriate.

• Address the reason the plan gave.
• Explain what outcome you are requesting.
• Include only relevant documents requested or needed for review.
• Keep originals and submit copies unless the instructions require otherwise.
• Use a verified insurer address, fax, or secure portal.
• Keep proof of submission and every response.

The Health Question cannot write, review, receive, or submit an appeal for you. Do not send us bills, EOBs, claim numbers, insurance IDs, diagnoses, records, identification, or financial documents.

Ask what happens to the bill while review is pending

Contact the provider’s billing office. Explain that the claim is being reviewed and ask whether billing or collection activity can be paused. Get the response in writing when possible. A dispute or appeal does not automatically place a bill on hold.

If the remaining balance is correct but unaffordable, coverage review and hospital financial assistance are separate processes. Read how to ask a hospital about financial assistance.

If the internal appeal is denied

The final decision should explain whether an external review is available and how to request it. External review uses an independent party, but not every denial is eligible, and the process depends on the plan and state. HealthCare.gov currently states that covered external-review requests generally must be filed within four months of the final denial notice. Follow the deadline and instructions on your own notice.

An external reviewer may uphold or overturn the plan’s decision; filing does not guarantee a different outcome.

Use the route for your coverage

• Private or Marketplace plan: follow the denial notice and plan instructions; a state Consumer Assistance Program or insurance department may help.
• Employer-sponsored plan: ask Human Resources whether the plan is self-funded or fully insured. The U.S. Department of Labor’s Employee Benefits Security Administration may help with many job-based plans.
• Medicare: use the appeal instructions on the Medicare Summary Notice or plan denial; Medicare has its own levels and deadlines.
• Medicaid: use the notice from your state Medicaid agency or managed-care plan; state procedures vary.
• Prescription denial: use our separate guide for a medicine the plan will not cover.

For future scheduled care, use the medical cost call planner to organize questions about network status, coverage rules, and expected charges before the appointment. Prior authorization and an estimate do not guarantee payment.

What to do today

1. Save the denial notice, EOB, and provider bill privately.
2. Circle the reason, date, deadline, and claim number.
3. Ask the insurer for the exact plan rule and next step in writing.
4. Ask the provider whether correction or resubmission is needed.
5. If it is a coverage decision, follow the internal-appeal instructions.
6. Ask what happens to billing while the review is pending.
7. Keep copies, call notes, and proof of every submission.

Official starting points

• CMS: Action Plan—Health insurance plan denied a claim
• HealthCare.gov: Internal appeals
• HealthCare.gov: External review
• U.S. Department of Labor: Filing a claim for health benefits
• CMS: Consumer Assistance Programs
• Medicare: Appeals
• Medicaid.gov: Beneficiary resources

Sources last checked September 6, 2026. Plan terms, deadlines, rights, costs, and review procedures can change. The denial notice and official plan or program instructions control your individual process.

This article provides general U.S. educational information. It does not interpret an insurance contract, provide legal, financial, medical, or insurance advice, prepare an appeal, determine urgency, or guarantee coverage, payment, or a billing hold.