What To Do After a Denied Claim
Getting a notice that a health insurance claim was denied can feel discouraging, especially if you were expecting the service to be covered. It can also be confusing. In some cases, the denial is based on missing information, coding issues, prior authorization requirements, medical necessity standards, or network rules rather than a simple final “no.” Washington consumers generally have the right to appeal a health plan’s denial, and for many plans there is also a process for independent external review.
If this happens to you, the most important first step is not to panic and not to assume the balance shown is automatically what you owe. Start by reading the denial carefully. Look at your Explanation of Benefits, denial letter, or other notice from the insurer. These documents usually explain what was denied, why it was denied, and what appeal rights or next steps may be available. Health plans are required to tell you why a claim or coverage request was denied and how you can challenge that decision.
Step 1: Find out exactly what was denied
A denial can apply to different things. Sometimes the insurer denies payment for care you already received. Washington’s Office of the Insurance Commissioner describes this as a post-service issue. In other cases, the insurer denies approval for treatment before you receive it, which is a pre-service issue. That distinction matters because the timeline and urgency of the appeal may be different.
It is also important to confirm whether the issue is truly a claim denial, a request for more information, an out-of-network issue, or even a possible surprise billing situation. In Washington, some out-of-network emergency and facility-based bills are protected under surprise and balance billing laws, and if you receive a prohibited balance bill, that is handled differently from a standard claim denial.
Step 2: Review the reason for the denial
The denial notice should give a reason. Common examples include:
• the service was considered not medically necessary
• the service required prior authorization
• the claim was filed with missing or incorrect information
• the provider was out of network
• the service was considered experimental or not covered under the plan terms
This is where details matter. Before assuming the insurer is correct, compare the denial reason to your plan documents, Summary of Benefits and Coverage, member portal information, and any communication from your provider’s office. Sometimes the problem is administrative. Other times, the denial may need clinical support from your doctor to challenge it effectively. Washington’s OIC specifically recommends using plan language and supporting medical documentation when preparing an appeal.
Step 3: Gather your documents before you respond
A stronger response usually starts with better documentation. Try to pull together:
• the Explanation of Benefits or denial notice
• your health insurance ID information
• claim numbers and dates of service
• any relevant plan documents or benefit summaries
• provider bills or statements
• notes from phone calls with the carrier or provider
• letters or chart notes from your doctor, if medical necessity is involved
Healthcare.gov recommends keeping copies of everything related to the denial and your appeal, including forms, letters, and notes from phone conversations. That can make a big difference if the issue continues or needs to move to a higher level of review.
Step 4: Contact the carrier or provider for clarification
In some cases, a quick call can help you understand whether the denial was caused by a processing issue, a billing code problem, missing documentation, or a plan rule. If the provider’s office submitted the claim, they may be able to correct or resubmit information. If the insurer says more documentation is needed, ask specifically what is missing and where it should be sent.
This step is also a good time to ask whether the service was denied because it was out of network, lacked prior authorization, or did not meet the insurer’s medical policy criteria. If medical necessity is the issue, Washington’s OIC notes that the appeal may need documentation showing how the treatment meets the insurer’s criteria.
Step 5: File an internal appeal if appropriate
If you disagree with the decision, you may have the right to file an internal appeal, which means asking the insurance company to review its own denial. Healthcare.gov states that consumers generally must file an internal appeal within 180 days of receiving notice of the denial. For urgent medical situations, the process can be expedited.
When you appeal, keep your response factual and focused. Washington’s appeal guide includes sample templates and notes that short, relevant factual statements are usually more effective than emotional or overly long letters. Include the claim number, date of service, reason given for the denial, and a clear explanation of why you believe the claim should be covered. Supporting letters from your provider can be especially important.
Step 6: Know when external review may be available
If the insurer upholds the denial after the internal appeal, you may have the right to request an external review, meaning an independent third party reviews the case. Washington’s OIC explains that the insurer assigns an Independent Review Organization, and for fully insured plans the review must generally be decided within 15 days after receiving all necessary information, or 20 days after referral, whichever is earlier. Urgent reviews move faster. If the Independent Review Organization overturns the denial, that decision is binding on the health plan.
That can be an important protection, because the insurance company does not always get the final say once an eligible external review is underway.
Step 7: Understand the difference between an appeal and a complaint
This is an area where people often get stuck. In Washington, an appeal is appropriate when you disagree with a health plan’s coverage or payment decision. A complaint is generally for situations where you believe the insurer or agent violated the law or treated you unfairly. The Washington Office of the Insurance Commissioner offers both complaint help and consumer advocacy support.
In other words, if the issue is “I disagree with this denial,” start by looking at the appeal path. If the issue is “I believe the insurer handled this improperly,” a complaint may also be appropriate.
Step 8: Remember that not all plans follow the same path
One of the most important Washington-specific details is that not every type of health coverage follows the exact same appeal process. Washington’s appeal guide notes that different rules may apply for Medicare, Apple Health, and some self-funded employer plans, and it recommends checking your specific plan type or contacting the appropriate administrator. It also notes that Human Resources may be the best source for confirming what type of employer plan you have.
That means the right next step may depend on whether your coverage is fully insured, self-funded, Medicare-based, or part of a public program.
How Maddock & Associates can help
Maddock & Associates can help you understand common benefits language, point you toward the documents you may need, and help you identify the next step to take. We cannot override a carrier’s decision, but we can often help you make the process feel more manageable by helping you understand what the denial is saying and where to go from there.
If you are facing a denied claim, a calm and organized response can go a long way. Start with the paperwork, confirm the reason, gather your documentation, and move through the appeal process step by step. A denial does not always mean the conversation is over.
Disclaimer: This article is for informational purposes only and is not legal, medical, or health advice. Benefits, coverage decisions, appeals rights, and billing protections vary by plan and situation. Always review your specific plan documents, carrier communications, and applicable regulations, and consult the appropriate carrier, provider, legal professional, or licensed advisor for guidance on your particular circumstances.
