Denial next-step guide
Choose the reason that is closest to what your notice or EOB says. You will see what it may mean, who usually acts first, and where to go next.
Is the care still needed, and could waiting seriously harm your health?
Yes, it may be urgent
Ask your plan for an urgent (expedited) review now. Your clinician can help. In many plans you can ask for an urgent external review at the same time.
No, or the care already happened: What reason does your notice give? ↓
What reason does your notice give?
Coding error, missing information, or billing mistake
What it may mean
The claim may have had a wrong code, missing detail, or typo. The plan may not have reviewed whether the care is covered.
Who usually acts first
The provider's billing office
Next steps
- Call the billing office and read them the denial reason.
- Ask them to correct and resubmit the claim.
- Ask them to hold the bill while it is fixed.
Learn more
Coverage not active, or wrong plan or ID
What it may mean
The plan could not match you to active coverage on the date of care.
Who usually acts first
You and the provider
Next steps
- Check that your coverage was active on that date.
- Give the provider your current card details.
- Ask the provider to resubmit to the right plan.
Learn more
Duplicate claim
What it may mean
The plan thinks it already received this claim. It may have been paid or processed under another claim.
Who usually acts first
The provider's billing office
Next steps
- Look for another EOB for the same date.
- Ask the provider whether the claim was sent twice.
- Pay only the amount on the correct EOB.
Learn more
Filed too late
What it may mean
The provider sent the claim after the plan's deadline.
Who usually acts first
The provider's billing office
Next steps
- Ask the provider why the claim was late.
- Ask whether you are responsible for the bill under their contract with the plan.
- Keep notes of the answer.
Learn more
Out of network
What it may mean
The provider or facility does not have a contract with your plan.
Who usually acts first
You, with help from the plan
Next steps
- Check whether it was an emergency or care at an in-network facility; surprise-billing protections may apply.
- Ask the plan whether an exception or in-network rate applies.
- If not, consider an appeal and use the appeal checklist.
Learn more
No prior authorization
What it may mean
The plan required approval before the care and did not find one.
Who usually acts first
The provider, then you
Next steps
- Ask the provider whether they requested approval.
- Ask if the plan allows a late (retroactive) request.
- If not, consider an appeal with your clinician's help.
Learn more
Not medically necessary
What it may mean
The plan reviewed the care and decided it did not meet its rules for medical need.
Who usually acts first
You and your clinician
Next steps
- Ask the plan for the rules or criteria it used.
- Ask your clinician for a letter and records that address those rules.
- File an appeal before the deadline on your notice.
Learn more
Not covered, excluded, or experimental
What it may mean
The plan says your benefits do not include this service.
Who usually acts first
You
Next steps
- Read the plan document section on this service.
- Ask your clinician whether a covered alternative exists or if the description was wrong.
- If you believe it is covered, file an appeal and quote the plan language.
Learn more
I am not sure, or the reason is unclear
What it may mean
Denial notices can be hard to read. You have a right to know why.
Who usually acts first
You, by asking the plan
Next steps
- Call the number on your notice and ask the plan to explain the reason in plain words.
- Ask whether the provider can fix it, or whether you need to appeal.
- Write down the deadline.
Learn more
Your notice has the deadlines and instructions that apply to you. This guide is general and does not predict a result.
Where can I go for help?
Free help is often close by: the member services number on your insurance card, the billing office for your provider, your state insurance department, and nonprofit patient advocates.
This is general education. For decisions about your own plan, taxes, or legal rights, check your plan documents or a qualified professional.