Whose job is it to fix this

Many denials sit between you, your provider and your plan, and each can point at the other. The reason on the letter usually tells you who acts first. Find the reason, find the owner, then ask that person what they will do and by when.

What this means

Four answers cover most cases:

• Your provider acts first when the claim itself was wrong: a coding or billing error, a duplicate claim, missing information, a claim sent late, or a prior authorization that the office should have requested.
• The plan acts first when it made a mistake, such as applying the wrong benefit, the wrong rate or the wrong coverage dates. You ask it to reprocess the claim.
• You and your provider act together when the denial is about medical judgment, such as “not medically necessary” or “experimental”. Your doctor supplies the clinical case; you hold the appeal rights.
• You act first when the denial turns on your coverage: another insurer is primary, your coverage was not active, or the service is excluded in a plan you chose.

Remember that the appeal deadline belongs to you, even if a provider agrees to help.

Reason on the letter	Usually acts first	What they do
Coding or billing error, duplicate claim	Provider	Corrects and resends the claim
Missing information	Provider, or you if it is yours	Sends the missing item
Filed too late	Provider (for an in-network provider)	Asks the plan to review, with proof of the date it was filed
No prior authorization	Provider and plan	Provider requests authorization; plan decides whether it can be given afterward
Another insurer is primary	You	Updates coverage details with both plans
Coverage not active	You, plan and employer	Confirms dates; employer or plan corrects records
Not medically necessary	You and your doctor	Appeal with clinical evidence

What to do

1. Write the reason down in the plan’s words. Then check the matching page in the denial reasons section or use the denial reason finder.
2. Call the provider’s billing office first for paperwork problems. Ask: “What did you send? What did the plan say was wrong? Will you correct it and resend, and by what date?” Note the name and date.
3. Call your doctor’s clinical staff for medical judgment denials. Ask whether the doctor will ask for a peer-to-peer review (a phone call between your doctor and the plan’s reviewing doctor) and write a letter supporting an appeal. The note to the doctor’s office can start the conversation.
4. If both point at the plan or at each other, set up a three-way call with the provider, the plan and you. Use the three-way call script.
5. Decide who will file. Your plan may let your provider appeal for you, but check what the office will actually do. Put your deadline on your own calendar.
6. If someone else will act for you, appoint them properly. See acting for someone else and the authorized representative designation.

What the office or plan may say, and what to say back

“We billed correctly. Take it up with your insurance.” Say: “Please send me the claim as it was submitted and the plan’s response. I want to see whether a code or a date is wrong.”

“We do not do appeals.” Say: “I will file one myself. Can you send the medical records and a letter from my doctor by [date]?”

“Your provider has to appeal that.” Say: “Who at the plan can confirm that in writing, and does it stop my own deadline?” Write down the answer.

The rule

Private plans must let an authorized representative act for you. In an urgent case, a health care professional who knows your condition must be allowed to act as your representative. Source: Code of Federal Regulations (CFR) Title 29, section 2560.503-1(b)(4), the federal claims regulation. Other programs set their own rules; check the date on your notice, which controls.

Watch for

• Medicare Advantage. Your treating physician can ask for a first appeal (called a reconsideration) after telling you. If the plan has already decided a payment for a contracted provider and you owe nothing, that decision is not part of the member appeal process.
• Medicaid managed care. A provider can file an appeal for you only with your written consent, if state law allows it. A provider cannot ask for continued benefits for you.
• TRICARE. A provider that does not accept TRICARE payment on the claim cannot appeal. You can.
• Original Medicare. You can name a representative using Form CMS-1696 from the Centers for Medicare & Medicaid Services (CMS), the federal agency that runs Medicare.
• Your provider’s incentives. A hospital often wants to be paid and may appeal a medical necessity denial itself. Ask, but do not wait on it.

What next

• Learn how the two sides file: patient and provider appeals.
• Prepare for the doctor’s call with the plan: peer-to-peer review.
• Sort the reason into a group: the three families of denial reason.
• Go to the topic page, find the real reason.