Answer
Why was my claim denied?
The short answer
A denial means your plan decided not to pay for some or all of a claim. The reason matters. Some denials are fixed when the provider corrects and resends the claim. Others need an appeal, which asks the plan to review its decision. Your notice should say which.
Key takeaways
- Start with the reason on the notice or EOB. It points to the right next step.
- Coding errors and missing details are often fixed by the provider's billing office, not by an appeal.
- Coverage decisions, such as "not medically necessary," usually need an appeal with supporting records.
Words in this lesson
- Denial
- A decision by your plan not to pay for all or part of a claim or a request for care. The notice should explain why.
- Claim
- A request for payment sent to your health plan, usually by your provider, after you get care.
- Medically necessary
- Care your plan agrees is needed to diagnose or treat a health condition, based on its rules. Plans may deny care they consider not medically necessary.
- Prior authorization
- Your plan's approval before certain care. Approval is not a guarantee of payment.
- Appeal
- A formal request asking your plan to review and change a decision, such as a denied claim or prior authorization.
Related
This is general education. For decisions about your own plan, taxes, or legal rights, check your plan documents or a qualified professional.