What to Do If Your Insurance Denied a Medical Bill?

Receiving a denial from your health insurance provider after expecting coverage for medical treatment can feel both confusing and overwhelming. But a denied medical bill doesn’t mean you’re out of options. With the right steps and persistence, you may be able to reverse the decision, reduce your financial burden, or find an alternative solution.

Why Medical Bills Get Denied

Before diving into how to respond, it’s essential to understand why your insurance may have denied a claim. Common reasons include:

• Out-of-network care: You received treatment from a provider not covered under your plan.
• Lack of prior authorization: Some procedures require pre-approval before insurance agrees to cover them.
• Not deemed medically necessary: The insurer believes the service was not essential to your health.
• Clerical or coding errors: Simple mistakes in billing codes or patient information can cause denial.
• Policy exclusions: Your plan may not cover certain treatments, medications, or conditions.

Step 1: Read the Explanation of Benefits (EOB)

The first step is to review your Explanation of Benefits, or EOB. This document explains:

• The services provided
• What was covered
• Why a claim was denied
• What you owe

Look for denial codes or notes that can give you clues about how to proceed.

Step 2: Call Your Insurance Company

Call the member services number on the back of your insurance card. Be polite but firm. Ask for specific information:

• Why the claim was denied
• If additional documentation can help reverse the decision
• How to formally file an appeal

Take detailed notes during the call, including the representative’s name, date of the call, and what was discussed.

Step 3: Double-Check the Medical Codes and Paperwork

Sometimes, claim denials are the result of coding errors. Ask your healthcare provider’s billing department to review the paperwork and confirm that:

• The correct CPT/diagnosis codes were used
• Your name, birthdate, and policy number are accurate
• The claim was submitted before the deadline

Step 4: File an Appeal

If the denial still stands, you have the right to file an internal appeal directly with your insurance company. Most insurers allow you to submit additional information, such as:

• A letter from your doctor explaining the medical necessity
• Medical records or test results
• Peer-reviewed journal articles that support the treatment

Make sure to meet the appeal deadline (usually 30-180 days from the denial) and follow the insurer’s procedures exactly.

Step 5: Request an External Review

If your internal appeal is denied, the Affordable Care Act gives you the right to request an external review—an independent, third-party review of your case. The insurer must accept the decision made in this process.

External reviews are often granted in cases involving:

• Experimental treatments
• Denied emergency care
• Claims involving life-threatening conditions

Step 6: Ask Your Healthcare Provider for Help

Some hospitals and clinics have patient advocates or billing specialists who can assist you with insurance appeals. They may also offer:

• Payment plans
• Financial assistance or charity care programs
• Re-submission of corrected claims

Step 7: Negotiate a Lower Bill

If the denial is final and you’re left with the bill, contact the provider directly to negotiate. Explain your situation and ask for:

• A discount for prompt payment
• A hardship-based reduction
• Monthly payment plans

Many providers prefer receiving some payment over none and may be more flexible than you expect.

Step 8: Seek Legal Aid or Advocacy

If you believe your denial was unjust or discriminatory, or if the bill is substantial, consider speaking with:

• A health care attorney
• A nonprofit patient advocacy organization
• Your state’s Department of Insurance

They can help you explore your legal options or even file a formal complaint.

Step 9: Know Your Rights Under the Law

Several federal laws offer protections for patients dealing with insurance denials, such as:

• Affordable Care Act (ACA): Provides rights to appeal and mandates coverage for essential services
• ERISA: Protects employees covered by employer-sponsored insurance plans
• HIPAA: Ensures your medical information is kept private and used appropriately during appeals

Step 10: Prevent Future Denials

To avoid dealing with medical bill denials in the future, consider the following tips:

• Call your insurer to confirm coverage before major procedures
• Always get preauthorization when required
• Use in-network providers whenever possible
• Keep meticulous records of treatments and insurance communications

Final Thoughts

Being denied coverage for a medical bill is frustrating, but you’re not powerless. Many patients successfully reverse denials by staying organized, following up promptly, and using their rights to appeal. Don’t let a single letter discourage you—there are steps you can take to fight back and protect your finances.

And if all else fails, remember that help is available—from nonprofit advocacy groups, state health departments, and legal aid clinics that specialize in healthcare rights and insurance disputes.