Understand What You Are Fighting
Your denial letter or EOB lists a reason code explaining why the claim was rejected. Read it carefully before calling anyone. Common reasons include medical necessity, out-of-network provider, missing authorization, and coding errors. The reason code determines your strategy — fighting a medical necessity denial requires clinical records, while fighting an out-of-network denial requires network adequacy arguments or surprise billing protections.
Request Your Complete Claim File
Call your insurer and request the full claim file including the original claim submission, adjudication notes, and the specific policy section cited in the denial. Under the Affordable Care Act, you have the right to access this information. Review it against your EOB to identify discrepancies — wrong diagnosis codes, missing authorization numbers, or services billed to the wrong policy are all appealable errors.
63% of provider-filed first-level appeals are overturned or partially paid. The denial is a starting point for negotiation, not a final decision — but only if you file before the deadline.
File Your Written Appeal on Time
Write a formal appeal letter identifying the claim, stating why the denial is incorrect, and attaching supporting documents. Submit before the deadline listed on your denial notice — typically 180 days for commercial plans. Send it via the method the payer specifies: portal upload, fax, or certified mail. Keep copies of everything with date stamps.
Escalate Through Every Available Level
If your first appeal is denied, file a second-level internal appeal. After exhausting internal options, request external review by an independent review organization. For surprise billing situations, federal No Surprises Act protections may apply independently of the standard appeal process. Each escalation level adds review depth and increases your cumulative recovery rate.
Start Fighting Your Denial Today
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