Guides

What to Do When Your Health Insurance Denies Care or Payment

How to understand a denial, find the right help, protect your appeal rights, and take the next steps.

You receive a letter saying your insurance company won't approve a treatment your doctor recommended. Or perhaps you've already received medical care and discover that your insurer won't pay the claim.

What happens next?

You may be told to contact your insurance company, ask your doctor to submit more information, or file an appeal. But which should you do first? Who can help you? And how do you know whether the denial is justified?

The answer depends on the type of denial, your insurance plan, and the reason the decision was made.

You don't need to become an insurance expert to challenge a decision. But you do need to identify the problem, understand your rights, and know where to turn for help.

This Guide will walk you through that process.

Step 1: Identify What Has Been Denied

Not all insurance denials mean the same thing, and treating them alike can send you through unnecessary paperwork.

A prior authorization denial generally occurs before treatment. Your healthcare provider has requested approval for a service, medication, or procedure, and the insurer has refused authorization. The provider may need to supply more clinical evidence, request reconsideration, or discuss an alternative treatment.

A claims denial usually concerns payment after services have been provided. The problem might involve incorrect billing information, missing documentation, the provider's network status, or an exclusion under your policy. Some of these problems can be resolved through correction and resubmission without requiring a formal appeal.

There are other situations that require particular attention. For example, you might receive notice that rehabilitation, home healthcare, or skilled nursing services are being reduced or terminated. Such decisions may have special appeal procedures and much shorter deadlines.

And if you've received an unexpected medical bill, don't immediately assume that the amount is your responsibility. Compare the bill with your insurer's Explanation of Benefits (EOB), which describes how the claim was processed. An EOB is not itself a bill.

Decision chart helping patients identify whether they received a prior authorization denial, a claims denial, an unexpected medical bill, or notice that ongoing care will be reduced or stopped.

Step 2: Take the First Five Actions

Once you've identified the problem, the goal is to establish what happened and protect your ability to challenge the decision.

Start with the written notice. Look for the service that was denied, the reason given, the date of the decision, and instructions for appealing. If the language is difficult to understand, contact the insurer and request an explanation in plain language. Ask for the specific plan provision or coverage criterion used to make the decision.

Next, identify the deadline for challenging the decision. This is important even if your doctor's office believes it can resolve the problem informally. A conversation with the insurer, a request for more information, or a corrected claim doesn't necessarily stop the formal appeal clock.

Ask your healthcare provider's billing or authorization department to review the denial. Find out whether an error can be corrected, whether additional medical records are needed, and whether the office has already requested reconsideration. Don't assume someone is handling an appeal unless you have confirmation.

When you speak with the insurer, record the date, the representative's name, and any reference number provided. If the representative promises a correction or further review, ask when you should expect an answer and how you can confirm that the request was received.

Five-step action sheet covering review of the denial notice, protection of deadlines, contact with the provider and insurer, and documentation of communications.

What if waiting could harm your health?

Don't automatically follow the routine appeal timeline when treatment is medically urgent.

Many plans provide expedited review when waiting for a standard decision could seriously jeopardize someone's life, health, or ability to regain function. Your physician may be able to explain why immediate review is medically necessary.

Ask specifically whether your situation qualifies for an expedited or fast appeal. Find out how your physician can support that request and what decision deadline applies.

If you are experiencing a medical emergency, seek appropriate emergency care rather than waiting for an insurance appeal to be resolved.

Step 3: Find Out Who Can Help You

One of the most frustrating parts of an insurance dispute is discovering that there isn't a single organization responsible for helping everyone.

The correct place to seek assistance depends largely on your coverage.

If you have Original Medicare, Medicare handles the claims and appeals process under its rules. If you have Medicare Advantage, your plan generally handles the initial appeal, with further review available through the Medicare appeals system.

Employer-sponsored coverage can be more complicated because some employers purchase insurance while others operate self-funded plans. Different regulatory agencies may have authority over those arrangements.

Medicaid programs also have their own processes, often involving managed-care plans and state agencies.

The practical starting point is usually the telephone number on your insurance card or denial notice. However, independent assistance can be valuable when the explanation is unclear, a dispute remains unresolved, or you need help understanding the correct appeals procedure.

Contact directory identifying assistance resources for Original Medicare, Medicare Advantage, private and employer insurance, Marketplace coverage, and Medicaid, with relevant telephone numbers and websites.

Additional help for Hawaii residents

Hawaii residents with Medicare can contact Hawaii SHIP, the State Health Insurance Assistance Program, for free Medicare counseling. The program helps people understand their coverage and navigate Medicare-related questions.

Hawaii SHIP: 808-586-7299 on Oahu or 1-888-875-9229 toll-free.

For complaints involving state-regulated private insurance, the Hawaii Insurance Division can explain its complaint procedures and jurisdiction. Its general number is 1-844-808-3222.

For many private employer-sponsored plans governed by federal employee benefits law, assistance is available from the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-3272.

These organizations have different responsibilities. Some provide counseling, some investigate complaints, and some explain legal rights. Not all of them will prepare or manage a complete appeal on your behalf.

That's why it's useful to ask a direct question when you call: "Can your office help me prepare or pursue this appeal, or can you refer me to someone who can?"

Step 4: Gather the Information Needed to Challenge the Decision

An appeal is more effective when it addresses the actual reason for denial rather than simply expressing disagreement.

If the insurer says a service wasn't medically necessary, the relevant information might include the physician's explanation, medical records, test results, previous treatments, and the clinical reasons the requested care is appropriate.

If the problem involves billing or administration, the most important evidence may be a corrected claim, proof of authorization, documentation showing that a service was provided, or confirmation that the patient had active coverage on the date of service.

Ask your provider which documents it can supply and whether it can submit clinical evidence directly to the insurer. You generally don't need to obtain every page of your medical record unless the dispute requires it.

Preparation checklist covering denial notices, insurance information, medical documentation, billing records, communication logs, and proof of submissions.

One additional precaution is worth emphasizing. Avoid sending original documents when copies are sufficient, and use secure methods for sharing medical information. Keep confirmation numbers, delivery receipts, or electronic submission acknowledgments whenever possible.

Step 5: Decide Whether You Need a Correction or a Formal Appeal

A formal appeal isn't necessarily the first or best response to every denial.

Suppose your provider submitted a claim using an incorrect code. The insurer might deny the claim because the information doesn't match its processing requirements. In that situation, the provider's billing office may be able to correct the claim and submit it again.

But suppose your insurer acknowledges that the information is accurate and still refuses to approve the treatment your physician recommends. That may require a formal appeal involving medical evidence and the plan's coverage criteria.

The distinction matters because the work involved is different. Correcting a claim is largely an administrative process. Challenging a medical-necessity determination requires explaining why the insurer's coverage decision should be reconsidered.

Don't let an informal correction process cause you to miss a formal appeal deadline. If you aren't sure whether the denial is being corrected or appealed, ask the insurer and provider to explain the status in writing.

Step 6: Know Your Appeal Deadline

There isn't one universal deadline for appealing a health insurance denial.

The following are common starting points, but the applicable notice and plan rules control your particular situation.

Medicare Advantage

For many Medicare Advantage appeals, the request for reconsideration must be filed within 65 days of the initial denial notice. Standard decisions generally have different processing timelines depending on whether care has already been received, and qualifying urgent cases can receive expedited review.

For example, many standard pre-service appeals have a 30-day decision period, while qualifying fast appeals generally require a decision within 72 hours. If a Medicare Advantage plan upholds certain denials at the first appeal level, the case proceeds automatically to an independent review entity.

Original Medicare

Original Medicare has a separate appeals system. Its initial appeal procedure generally involves requesting a redetermination after receiving a Medicare Summary Notice or other applicable decision notice. Some situations, such as termination of certain continuing services, involve special expedited procedures.

Follow the instructions and deadline on your notice rather than relying on Medicare Advantage rules.

Private and employer health plans

Many plans subject to federal health benefit appeal protections must give members at least 180 days to initiate an internal appeal. The insurer's decision period depends on whether the dispute concerns urgent care, care not yet received, or a service already provided.

For certain decisions, an independent external review may also be available, usually after completing the internal appeals process. Under the federal external review framework, the ordinary filing deadline is generally four months after the applicable final denial notice.

Medicaid

Medicaid and managed-care plans have their own rules, including procedures for appealing benefit denials, reductions, or termination of services. Follow the notice and the rules of the relevant state Medicaid program or managed-care plan.

An especially important exception applies to services being stopped or reduced. Some programs have short deadlines for requesting continuation of benefits while an appeal is pending. Don't assume you have the same amount of time as someone appealing payment for an already completed service.

Because appeal rules change and depend on coverage, always confirm the applicable deadline directly with your plan or responsible agency.

Step 7: What If Your Doctor's Office Can't Keep Fighting?

This is one of the most difficult practical problems.

Your physician may strongly support a treatment, but the practice also has patients to see, medical records to maintain, employees to pay, and many other administrative obligations. Insurance disputes can consume substantial time, and providers aren't necessarily paid separately for all the work involved.

If your doctor's office tells you it cannot do more, try to identify exactly what assistance is still possible.

For example, the office may not have the resources to manage repeated appeals, but your physician might be willing to provide a medical-necessity letter, identify the relevant clinical records, or explain the consequences of delaying treatment.

You can also ask whether the office has a patient advocate, care coordinator, or referral to a hospital or health-system patient assistance service.

If the dispute concerns a Medicare plan, a SHIP counselor may help you understand the process. For qualifying private insurance disputes, a consumer assistance program, insurance regulator, or federal benefits advisor may help clarify your rights.

More complicated cases may justify contacting a legal aid organization or attorney familiar with health insurance disputes, particularly when substantial medical expenses, loss of benefits, or continuing-care decisions are involved.

The important point is that you don't have to rely exclusively on your doctor's office, even though your physician's medical evidence may remain essential to the appeal.

Step 8: What If the Appeal Is Denied Again?

An unsuccessful internal appeal doesn't always end the process.

Depending on your insurance arrangement and the kind of dispute, an independent reviewer may examine the insurer's decision. This may be called external review, independent review, or another level of appeal.

For many eligible private health-plan disputes, external review provides an assessment by someone outside the insurance company. Medicare has its own multi-level appeals structure, including independent review at a subsequent stage.

Read the appeal decision carefully. It should explain why the insurer maintained the denial and identify any further review rights that apply.

At this stage, ask what additional information or evidence could address the decision. If the dispute turns on medical necessity, your physician may be able to explain why the insurer's criteria don't adequately reflect your circumstances. If the dispute concerns coverage language, you may need help interpreting the plan document.

If the available appeals have been exhausted, additional legal or regulatory options may exist, depending on the plan and circumstances.

Don't Overlook Unexpected Medical Bills

Not every unexpected bill results from a legitimate patient obligation.

Sometimes an insurer denies a provider's claim because it was submitted incorrectly. In other situations, the amount charged may be subject to contractual restrictions or federal and state protections against certain surprise medical bills.

For example, the federal No Surprises Act protects many patients from certain out-of-network bills for emergency services and specified services furnished at in-network facilities.

Before paying a large unexpected bill, compare the provider's statement with the insurer's EOB and ask both parties to explain the amount.

If you suspect a violation of federal surprise-billing protections, the No Surprises Help Desk can provide information at 1-800-985-3059.

The key lesson is simple: A denied claim and a bill from a provider don't automatically establish that every dollar billed is your responsibility.

Keep a Record Until the Matter Is Resolved

Insurance disputes can involve several telephone calls, multiple documents, and different representatives. Without a written record, it becomes difficult to determine what has already been promised, submitted, or reviewed.

A simple notebook or digital folder can make a difference. Record the date of every conversation, the name or identification number of the person you spoke with, the instructions given, and any deadline or expected response date.

If you send an appeal, save a copy and proof of submission. If someone tells you a claim will be corrected or a decision reconsidered, request a confirmation or reference number.

Once the issue is resolved, verify that the insurer's updated decision is reflected in the claim or authorization record and that the provider's billing information has been adjusted where appropriate.

An approval letter is important, but the process isn't necessarily complete until the promised coverage or payment has actually been implemented.

Taking Control When Insurance Says No

Receiving a denial can be intimidating, especially if you're already dealing with a medical problem. But a denial notice is information about a decision, not necessarily the final word on whether you can receive care or whether you owe a medical bill.

Your first responsibility isn't to become an expert in healthcare law. It's to identify the decision, preserve your deadlines, determine who can help, and gather the information needed to address the actual issue.

Sometimes a corrected claim will resolve the problem. Sometimes a formal appeal is necessary. And sometimes independent assistance becomes the most important next step.

The more clearly you understand what was denied, why it was denied, and who has authority to review the decision, the better equipped you'll be to protect your interests.

Sources and Further Reading

Medicare: Appeals in Medicare Health Plans

https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans

Medicare: Appeals in Original Medicare

https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/original-medicare

HealthCare.gov: Internal Appeals

https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/

HealthCare.gov: External Review

https://www.healthcare.gov/appeal-insurance-company-decision/external-review/

U.S. Department of Labor: Filing a Claim for Your Health Benefits

https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-health-benefits

Hawaii SHIP

https://www.hawaiiship.org/contact/

Hawaii Insurance Division: Filing a Complaint

https://www.cca.hawaii.gov/ins/complaint/

Hawaii Med-QUEST: Grievances and Appeals

https://medquest.hawaii.gov/en/members-applicants/rights-and-responsibilities/grievance-appeals.html

Note from Marsha

In researching insurance denials, I've become particularly interested in what patients are expected to do after receiving one. The process can demand considerable time and knowledge from people who may already be dealing with the adverse consequences of illness.

I developed this Guide because I don't think simply telling someone to "file an appeal" is particularly helpful. People need to know where to start, who can assist them, and what information to gather.

My hope is that these steps and accompanying reference sheets will make a difficult process easier to navigate.

Where You Might Want to Go Next

Health Insurance Denials: Who Bears the Cost of Fighting Back?

Explore the broader questions about insurance denials, appeal rates, administrative burdens, and whether the system creates incentives for delays.

Original Medicare vs. Medicare Advantage

Understand how these two coverage arrangements differ, particularly when specialized treatment, hospitalization, or rehabilitation becomes necessary.

Understanding Your Health Insurance Costs

Learn how deductibles, negotiated rates, coinsurance, and coverage limitations influence what you actually owe.

The first article is published. The other two are planned companion resources.