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Few moments are more stressful than opening a letter or Explanation of Benefits (EOB) and discovering your health insurance claim has been denied. Whether it’s coverage for an essential medication, a needed medical procedure, or an unexpected hospital stay, a denied claim can throw your budget—and peace of mind—into turmoil.
Many denials are simply the result of missing information, administrative errors, or confusion over your coverage. With step-by-step guidance and the digital tools offered by Beem Health, you can approach claim denials with clarity and confidence—often turning a “no” into a “yes.” This blog will explain why claims are denied and outline the steps to take if your health insurance claim is denied.
Why Health Insurance Claims Get Denied
Recognize that claim denials are common. Insurance companies process millions of claims each year, and mistakes happen. Here are the most frequent reasons:
- Missing Information or Errors: Incomplete forms, incorrect patient details, wrong billing codes, or submission mistakes.
- Non-Covered Services: Procedures or medications that fall outside your plan’s benefits, such as experimental treatments, cosmetic surgery, or elective services.
- Out-of-Network Providers: Seeking care outside your plan’s provider network can result in automatic denials or reduced coverage.
- Lack of Pre-Authorization: Many services, like surgeries or advanced imaging, require insurer approval ahead of time. Skipping this step triggers denial.
- Medical Necessity Not Established: If the insurer believes the service wasn’t necessary, they may reject the claim until further evidence is provided.
- Duplicate Claims: Submitting a claim multiple times can result in rejection.
- Policy Coverage Lapses: Coverage may have lapsed if your premium wasn’t up to date when the service was received.
Key requirement: By law, insurance companies must provide a written explanation of every denial, including the reason, the exact benefit in question, and instructions on how to proceed.
Beem Health helps you review denial letters, decode complex language, and determine what to do next.
Immediate Steps to Take After a Claim Denial
1. Review the Denial Notice Carefully
- Read the explanation of benefits (EOB) or denial notice. This document outlines the date of service, type of service, the reason for denial, and any missing information.
- Identify specifics: Note the claim number, the exact service/medication denied, and the insurer’s stated rationale.
Tip: Beem Health’s app can help you interpret confusing terminology and break down dense EOBs step-by-step.
2. Check Your Policy Details
- Locate your plan documents: Review your policy, coverage rules, and summary of benefits. Determine if the denied service should be covered.
- Check for exclusions and requirements: Look for clauses about pre-authorizations, medical necessity, and network restrictions. Many denials stem from simple misinterpretations of policy terms.
Beem Health provides digital access to your plan in one place, making this process easy even on the go.
3. Gather Supporting Documentation
- Collect medical records: Secure all relevant provider notes, lab results, bills, referral letters, and any correspondence about the service.
- Confirm pre-authorizations: If you obtained prior approval, include copies of authorization letters or emails.
- Organize everything: Use digital folders or Beem Health’s secure app to store and structure all your documents.
Thorough paperwork will make any appeal faster and more likely to succeed.
How to Appeal a Denied Health Insurance Claim
An initial denial is not final. State and federal regulations guarantee your right to challenge (appeal) a health insurance denial, and many claims are ultimately approved after review. Appeals can be complex or straightforward, but the process is well-defined.
1. Contact Your Insurance Company
- Call customer service: Use the phone number on your insurance card or denial letter. Record the date and time, the representative’s name, and any reference or case numbers provided.
- Clarify the denial reason: Ask specific questions such as:
- Was an error made on the claim?
- Was pre-authorization missing?
- Is additional information from your provider needed?
- Document everything: Take detailed notes or, better yet, use Beem Health to keep a call log and attach it to the claim record.
Don’t assume a denial is final—sometimes, a brief conversation resolves errors or missing data without the need for a formal appeal.
2. File a Formal Appeal
- Follow appeal instructions: The denial letter or your policy will explain the exact steps; it often specifies how to submit an appeal, which documents are needed, and deadlines.
- Write a clear appeal letter: Include:
- The denied claim number and date of service
- A concise explanation of why you disagree with the denial
- Any relevant medical information or letters from your provider supporting the necessity of treatment
- A copy of the EOB/denial notice
Beem Health offers step-by-step templates, sample letters, and checklists for compiling every required component.
3. Work with Your Healthcare Provider
- Request a letter of medical necessity: Ask your doctor to submit an explanation detailing why the treatment or medication was needed, referencing policy language or medical standards.
- Supply extra documentation: Providers can offer progress notes, test results, and evidence the requested service ties to your diagnosis.
Providers deal with appeals regularly and often have dedicated billing staff to help strengthen your submission.
4. Escalate the Appeal if Needed
If your insurer upholds the denial after your first appeal (sometimes called an “internal appeal”), further actions are available:
- Request an external review: By law, you have the right to an independent, third-party review at your request. The decision of this reviewer is binding for the insurer.
- Contact state regulators: Your state insurance department or consumer assistance program can intervene, particularly if timelines aren’t followed or you face repeated denials without explanation.
- Consult ombudsmen or legal advocates: For complex or urgent denials, especially involving life-saving care, professional help increases your odds.
Tips for Preventing Future Claim Denials
While not all denials are avoidable, these best practices cut your risk:
1. Double-Check All Submissions
- Review each claim for typos, missing patient information, incorrect dates, or absent codes.
- Confirm every form is signed and all attachments are included.
2. Understand Coverage Requirements
- Before receiving care, check if pre-authorization, referrals, or proof of medical necessity is required.
- Use only in-network providers and facilities whenever possible.
3. Keep a Detailed Health Record
- Maintain copies of all bills, authorizations, and prescription records.
- Use Beem Health’s digital claim tracking and alert system to monitor processing and receive instant alerts if a claim is pending, delayed, or denied.
4. Communicate Regularly
- Notify your insurer right away about changes to your address, coverage, or dependents.
- Reach out to your provider’s billing team for help with unusual cases.
Conclusion
A denied health insurance claim isn’t the end of your coverage—many denials stem from administrative issues and are overturned on appeal. You can resolve most issues without professional legal help with the right approach and documentation. Beem Health empowers you through every step. Whether you’re facing your first denial or a recurring problem, the right tools and informed approach help you protect your health, finances, and peace of mind.
Beem Health is a cost-effective, secure, and user-friendly platform that ensures individuals have convenient and reliable access to essential healthcare services. Sign up for Beem Health — from the house of Beem, the personal finance app trusted by over 5 million Americans — today and discover easy and rewarding healthcare. Download the app here.
FAQs About Steps to Take if Your Health Insurance Claim is Denied
Why do health insurance claims get denied?
Common reasons for denial include missing or incorrect information, services not covered under your policy, use of out-of-network providers, lack of required pre-authorization, and administrative errors. Reviewing your denial notice to understand the reason your claim was rejected is important.
What should I do first when my claim is denied?
Start by reading the denial letter or explanation of benefits (EOB). Identify the reason for denial, gather all supporting documents, and review your policy to confirm if the service is covered and whether any pre-conditions like authorizations were needed.
How do I file an appeal for a denied claim?
Appeals typically involve submitting a written request to your insurer, including the original denial notice, a clear explanation of why you believe the claim should be approved, and all supporting documentation, such as medical records or provider notes. Follow your insurer’s specific appeal process and adhere to any deadlines.
How long do I have to submit an appeal?
Most insurance plans give you 60 to 180 days from the date you receive the denial notice to submit a formal appeal. The exact timeframe should be listed in your denial letter and policy documentation.
Can my healthcare provider help with the appeal?
Yes. Providers can supply letters of medical necessity, clarify the need for treatment, and furnish additional documentation to support your case. Their involvement can be critical to a successful appeal.
What if my internal appeal is denied?
You have the right to request an external review by an independent third party. The insurance company must cover the claim as ordered if the external reviewer overturns the denial.
How can I prevent claim denials in the future?
Check that services are covered and pre-authorized, use in-network providers, complete all forms, and double-check for errors before submission. Keeping organized records and communicating with providers can also reduce risk of denial.
What documents should I keep for a claim or appeal?
Keep the denial letter or EOB, your insurance policy, pre-authorization records, doctor’s notes, referrals, related medical bills, and a log of all communications with your insurer and provider.
Can Beem Health assist if I experience repeated denials?
Yes. Beem Health offers real-time claim tracking, secure document storage, templates for appeal letters, and guidance throughout every step of the appeal process to help resolve ongoing or complex cases.
What rights do I have if I believe my claim was wrongly denied?
You have the right to a clear explanation for the denial, to file an appeal, to request an external independent review, and to seek assistance from your state’s insurance regulator or a consumer support program if necessary. Always review your plan documents to understand your appeal rights and timelines fully.
