Find the real reason

Guides

• The three families of denial reason

  Almost every denial reason falls into one of three families: paperwork, coverage or clinical. Knowing which one you have tells you who acts first and what evidence helps.

• Whose job is it to fix this

  Work out who must act first on a denial: you, your provider, the plan, or you and your provider together. Then learn how to get the right person moving.

Tools

• Tool

  Denial reason finder

  Match the wording on your letter to a denial reason, see who must act first, and open the right playbook.

Letters and scripts

• Letter or script

  Phone script: first call after a denial

  What to say and ask on your first call to your plan after a denial, and what to write down before you hang up.

Denial reasons

• Denial reason

  Allowed amount too low

  Your plan paid an out-of-network provider only part of the bill and says the rest is above its allowed amount. Check how the plan set that amount, whether surprise-billing protections apply, and what typical prices are in your area.

• Denial reason

  Another insurer is primary

  The plan says another insurance plan must pay first, or it wants the other plan's decision before it pays. Only you know all your coverage, so you usually have to sort out the order and tell both plans.

• Denial reason

  Bundled or included in another service

  Your plan folded the charge for one service into the payment for another from the same visit, so it paid nothing for it. Often the provider's billing office can correct the claim, so start there.

• Denial reason

  Care is ending

  Hospital, rehab, nursing home or home health care ending? Medicare: call the reviewer on your notice by noon the day after you get it, or 1-800-MEDICARE (1-800-633-4227). Medicaid or job-based plan: see What to send.

• Denial reason

  Coding or billing error

  The claim itself has a wrong code, a wrong detail or a missing item. Your provider's billing office usually has to correct it and send it again. You help by asking for the codes, checking them against your records and following up.

• Denial reason

  Cosmetic

  Your plan says the surgery or treatment is meant to change how you look, not to treat a medical problem. The fight is usually over whether it treats a real medical or functional problem, and over the plan's own definition of cosmetic.

• Denial reason

  Coverage not active

  The plan says you were not covered on the date of service. Find out why, because a plan or employer error, a missed premium and a cancelled policy each have a different fix, and the deadline to act may be short.

• Denial reason

  Coverage rescinded

  Your plan says it is cancelling your coverage retroactively, as if it never existed, because of your application. Federal rules allow that only for fraud or an intentional misrepresentation of a material fact, with 30 days' written notice.

• Denial reason

  Custodial care

  Your plan says the nursing, home health or facility care you get is help with daily living, not skilled medical care. If skilled staff are doing the work, you can challenge the label, and Medicare does not require that you are improving.

• Denial reason

  Dental or vision boundary

  Your medical plan says the care belongs to your dental or vision plan, and the dental or vision plan may say it belongs to medical. Get both answers in writing and compare each to the plan's own wording.

• Denial reason

  Drug not on the formulary

  The drug your doctor prescribed is not on the plan's list of covered drugs. You can ask for an exception. Your prescriber will need to state why this drug, and not the covered ones, is right for you.

• Denial reason

  Duplicate claim

  The plan thinks it already received or paid this claim. Check your Explanation of Benefits for the first claim. If the services are separate, your provider's billing office has to show the plan that.

• Denial reason

  Experimental or investigational

  The plan says the treatment is unproven or still being tested. That is a medical question, so the appeal rests on evidence. Independent external review is open if your plan is not grandfathered, short-term, fixed indemnity or a sharing ministry.

• Denial reason

  Filed too late

  The plan says the claim reached it after its filing deadline. If your provider was supposed to file it, the late filing is usually the provider's problem to fix. Ask for proof of when the claim was sent.

• Denial reason

  Level of care

  Your plan agrees you need treatment but says a less intensive setting would do. For example, outpatient care instead of residential care, or a lower-intensity program instead of a hospital stay.

• Denial reason

  More information needed

  The plan has not decided yet, or it denied because something it asked for did not arrive. Read exactly what it wants, find out who holds it, and send it in a way you can prove. The plan must give you time to respond.

• Denial reason

  No prior authorization

  The plan says approval was needed before the service and was not obtained. Find out whether approval was really required, who was supposed to ask, and whether getting it was impossible. Your provider often has to act.

• Denial reason

  No referral

  Your plan says a referral was needed before you saw a specialist and none was on file. Sometimes the referral was given but never recorded, or the paperwork can be fixed, so call both offices before you appeal.

• Denial reason

  Not a covered benefit

  The plan says your policy does not cover this service. Read the exact exclusion, check whether the service really falls inside it, and check whether a law requires the plan to cover it anyway.

• Denial reason

  Not an emergency

  Your plan says your emergency room visit was not a true emergency, so it denied the claim or paid it at a lower rate. The test is what your symptoms looked like to an ordinary person, not the final diagnosis.

• Denial reason

  Not medically necessary

  The plan says the care is not needed under its own definition. That is a medical judgment, so your doctor's letter carries the appeal. Independent external review is open if your plan is not grandfathered, short-term, fixed indemnity or a sharing ministry.

• Denial reason

  Observation instead of inpatient

  The hospital kept you but billed the stay as outpatient observation. If you were formally admitted and then switched, you can appeal in two cases, and must ask before you leave to keep billing protection. If never admitted, this right does not apply.

• Denial reason

  Out of network

  The plan says your provider or facility is not in its network. Federal law protects you in emergencies and in several hospital situations, so check which situation you are in before you pay.

• Denial reason

  Preventive care billed as diagnostic

  You went for a recommended screening or checkup that should have cost nothing, but the claim was coded as diagnostic, so you were charged. Sometimes a corrected claim from the provider fixes it.

• Denial reason

  Prior authorization denied

  Your doctor asked the plan to approve care in advance and the plan said no. The clocks are short, and your doctor can ask for a doctor-to-doctor call. Independent external review is open if the reason is medical and your plan is not grandfathered.

• Denial reason

  Quantity or dose limit

  The plan covers your drug but only up to a set amount or on a set schedule. If your prescriber ordered more, you can ask the plan whether it has an exception process for this limit. It turns on your dose, your history and what happens at lower amounts.

• Denial reason

  Step therapy required

  The plan wants you to try cheaper drugs first. You can ask for an exception. Holding a denial letter? File the appeal by your deadline, and ask your doctor to send the exception request at the same time.

• Denial reason

  Visit or benefit limit reached

  Your plan says you used up the visits, days or dollars it covers for a service this year. Check the count, check whether the plan allows more when it is medically necessary, and check whether mental health care is limited more than other care.

• Denial reason

  Waiting period or pre-existing exclusion

  Your plan says the care came before your coverage kicked in, or that it excludes a condition you had beforehand. Check the dates first, because many of these are date errors, and ask which rule the plan used.

• Denial reason

  Wrong site of service

  Your plan will pay for the service but not where your doctor wants it done, such as a hospital outpatient department instead of a doctor's office. Whether the setting is safe for you is a medical judgment you can challenge.

Programs and services

Run by other organizations.

• Program or service

  Arthritis Foundation Rx for Access insurance toolkit

  A multi-page toolkit and a helpline for people with arthritis covering claims, common denial reasons, explanation of benefits, and appeals for private and government plans. Condition-specific: arthritis, including juvenile arthritis.

  From Arthritis Foundation

• Program or service

  National Alliance on Mental Illness guide to insurance denials

  A plain explanation of why mental health care is denied, five signs of a possible parity violation, and a link to a longer appeals guide written with The Kennedy Forum. Information only.

  From National Alliance on Mental Illness