What Should I Do If My Insurance Claim Is Denied?

An insurance claim denial is not the final answer. There are steps you can take to appeal it and often get it overturned.

In 2024, insurers on HealthCare.gov denied 19% of in-network claims, but fewer than 1% of those denials were ever appealed. Of the people who did appeal, about one in three got the decision reversed. In Medicare Advantage, plans overturned 67% of appealed prior authorization denials in 2025. Almost nobody appeals. Many people who do appeal win.

Most denials are not medical judgments either. Only 5% of in-network denials in 2024 were based on medical necessity. A quarter were administrative.

Two Umbra Health Advocacy advocates have spent years overturning these decisions.

Jenni Nolan, BCPA, is a Board Certified Patient Advocate who specializes in medical billing, claims, and appeals. She spent more than 20 years in practice management working unresolved claims and incorrect bills.

Sara Du Terroil is a healthcare advocate and insurance consultant who focuses on mental and behavioral health. She is a former labor law attorney and lifetime special needs mom and also has more than 20 years of advocacy experience. Here is what they want you to know, and what they say you should do.

First, Know What Kind of Denial You Have

A denial can arrive at two different moments. Sara explains the difference:

“Be ready for a denial at any stage. Even care that was approved in advance can be reviewed again when the claim is submitted. This is called utilization review. A denial can happen before service, when the plan denies the authorization, or after service, when the plan denies the claim. Both can be challenged.” Sara Du Terroil

12 Steps To Take After a Claim Denial

1. Do not panic, and do not assume the denial is final.

“Many of the denials I see are administrative rather than medical. Missing information, coding errors, or insurance processing issues can all lead to denials that are ultimately reversible.” Jenni Nolan, BCPA

Reach out to the provider or facility billing office to see if they are already working on the denial. If they are, the problem may be resolved before you ever receive a bill. If it does not get resolved, it is time for you to get to work.

2. Read the denial carefully.

Look for the specific reason code and explanation on the Explanation of Benefits (EOB) or denial letter. Understanding why the claim was denied determines the next step.

3. Verify that the provider billed correctly.

Coding errors, missing modifiers, incorrect information, or duplicate billing can all trigger denials. Ask the provider’s billing office to review the claim before you appeal.

4. Know your insurance benefits.

Review your Summary of Benefits and Coverage or insurance policy documents. Determine whether the service is covered, whether prior authorization was required, and whether network rules apply.

5. Pay attention to appeal deadlines.

Insurance companies have strict timelines for filing appeals. Missing the deadline can eliminate your right to challenge the decision.

6. Keep detailed records.

Save every EOB, bill, letter, and email. Good documentation can make the difference during an appeal.

“Be ready to keep good records. Save copies of authorization requests, denial letters, and any medical records you submit. Write down the date, the name of each person you speak with, and the reference number for every call.” Sara Du Terroil

7. Request the insurer’s full explanation.

If the denial is not clear, ask for the clinical criteria, medical policy, or internal guidelines used to make the decision. You have the right to understand how the decision was reached.

“Coverage decisions are based on whether your situation matches the plan’s clinical criteria, not simply on whether you and your clinician believe treatment would help. Ask for the exact criteria used to review your request. Your provider’s office or a case manager can often help you find and understand them.” Sara Du Terroil

8. Work with your healthcare provider.

Your physician can often provide additional documentation, corrected coding, or a letter of medical necessity that addresses the insurer’s specific concerns. Coverage decisions often turn on details like symptom severity, safety concerns, how long symptoms have lasted, how daily life has been affected, past treatments, and how you responded to them. Make sure your provider has your most complete and current information.

9. Do not accept the first “no.”

Many denials are overturned once more clinical information is added.

“Many insurers have multiple levels of appeal, and some cases qualify for an independent external review. A denial is often just the beginning of the process, not the end.” Jenni Nolan, BCPA

10. Review your financial assistance options.

If the denial ultimately stands, ask the provider about financial assistance, charity care, prompt-pay discounts, or payment plans. Many hospitals have programs that people never realize they are eligible for.

11. Know your rights.

Depending on your state and your insurance plan, you may have protections under state law or federal law, including the right to an external review for certain medical necessity denials.

“Sometimes even the mention of involving the regulator will make the health plan and/or the employer pay more attention to your case”.  Sara Du Terroil

If the Denial Involves Mental or Behavioral Health Care

Mental and behavioral health denials have their own patterns. Care is more likely to be out of network. Plan criteria are more likely to drift from generally accepted standards of care. A strong appeal answers the plan on its own terms, and Sara builds hers around three questions:

• Were the plan’s criteria in line with generally accepted standards of care for your condition?
• Which specific criterion did the plan say was not met?
• What clinical documentation would make the appeal stronger?

The Biggest Mistake

“The biggest mistake I see people make is assuming a denial is the final answer. In reality, it is often just the first step in a process.” Jenni Nolan, BCPA

Asking questions, staying organized, meeting deadlines, and getting experienced help when needed can dramatically improve your chances of overturning a denial or reducing what you owe.

Feeling Overwhelmed? You Do Not Have To Do This Alone

Appeals take time, paperwork, and persistence. If you are sick, caring for someone who is, or simply out of patience with hold music, that is a lot to carry.

Umbra Health Advocacy works with credentialed patient advocates that are appeals experts, just like Jenni and Sara. Contact us to consult with Jenni or Sara or call 332-699-6778.