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Why insurance claims get denied

Insurance denials are frustrating but common. The good news is that many denials can be overturned on appeal. Understanding why your claim was denied is the first step.

• Medical necessity: Insurer says the treatment was not needed.
• Prior authorization: Treatment was not pre-approved.
• Out of network: Provider was not in your plan network.
• Coverage limits: Service exceeds your policy limits.
• Coding errors: Wrong diagnosis or procedure codes.

Your right to appeal

Under the Affordable Care Act, you have the right to appeal any insurance denial. There are two levels of appeal: internal (with your insurer) and external (with an independent reviewer).

You typically have 180 days from the denial to file an internal appeal. Make sure to act quickly.

What to include in your appeal letter

A strong appeal letter should include:

• Your policy information and claim number.
• Clear statement that you are appealing the denial.
• Reason the claim was denied (from the denial letter).
• Why you disagree with the denial.
• Supporting documentation (medical records, doctor letters).
• Request for expedited review if urgent.

Medical necessity appeals

For medical necessity denials, you need documentation from your doctor explaining why the treatment was necessary. Include clinical notes, test results, and any medical literature supporting the treatment.

We provide templates that include the right language and structure for medical necessity arguments.