DENIED CLAIM
My EOB says the claim was denied. What does that mean, and can I appeal?
A denied claim means your insurer decided not to pay for that service, and the EOB or a letter should say why. You can ask the insurer to reconsider through an internal appeal — HealthCare.gov says you must file within 180 days of being told the claim was denied — and, if it is still denied, ask for an external review.
Why it’s confusing
Denials are explained in short codes and phrases — “not medically necessary”, “prior authorization required”, “out of network”, “duplicate claim” — that hide very different problems. Some are simple paperwork errors a provider can fix by resubmitting; others need a formal appeal.
A denial on an EOB also doesn’t mean a bill is coming tomorrow, but it may mean the provider bills you for the full amount, so it is worth acting early.
How to read it
Find the reason. Look for a remark or reason code next to the denied line, and the key that explains it — often on the back or last page of the EOB. Your insurer must tell you in writing why the claim was denied.
Sort it into one of two kinds. A billing or paperwork problem (wrong code, missing information, duplicate) is often fixed by the provider correcting and resubmitting the claim — call their billing office first. A coverage decision (not medically necessary, not covered, experimental) is what the appeal process is for.
To appeal, HealthCare.gov says you complete your insurer’s forms or write to it with your name, claim number and insurance ID, and you can include extra information such as a letter from your doctor. File within 180 days of receiving the denial. If the insurer still says no, you can ask for an external review — an independent decision your insurer must accept — within 4 months of the final denial. In an urgent health situation you can ask for both at the same time.
What it does not mean
- That you definitely owe the full amount. A corrected claim or a successful appeal can change it.
- That the care was wrong or unnecessary. “Not medically necessary” is a coverage decision, not a medical verdict.
- That there is nothing you can do. Keep copies of the EOB, the denial and everything you send.
Where you’ll see it
- Insurance EOBs, as “denied”, “not covered” or “$0 paid” with a reason code.
- Denial letters, sometimes called an adverse benefit determination.
Questions worth asking
Ask your insurer
- What exactly is the reason for this denial?
- Is this something the provider can correct and resubmit?
- How do I file an internal appeal, and what is my deadline?
Ask the provider’s billing office
- Was the claim coded correctly?
- Can you resubmit it, and will you hold the bill while it is reviewed?
Got a denial you can’t make sense of? Attach the EOB or letter, and Clariti will explain the reason and what to ask.
Common questions
- How long do I have to appeal a denied claim?
- HealthCare.gov says you must file an internal appeal within 180 days (6 months) of receiving notice that your claim was denied. Your denial notice should state your deadline.
- What is an external review?
- An independent review of your insurer’s decision. HealthCare.gov says you must request it in writing within 4 months of the final denial, and your insurer must accept the reviewer’s decision.
- Should I call the provider or the insurer first?
- If the reason looks like a coding or paperwork error, the provider’s billing office can often fix and resubmit it. For coverage decisions, contact your insurer about an appeal.