Top 5 Reasons Health Insurance Claims Get Denied, and What You Can Do

Why Was My Health Insurance Claim Denied?

Top 5 Reasons, and How You Can Take Back Control

When your health is on the line, a denial from your insurance company can feel like a punch to the gut. You did everything right: saw your doctor, followed their recommendations, and submitted the claim. So why was it denied?

At Appeal Healthcare, patients deserve answers and a realistic path forward. Below are the five most common reasons insurance companies deny medical claims, followed by step-by-step actions based on the plan you have (ERISA, ACA Marketplace, or private insurance).

1. No Prior Authorization

Many insurance plans require prior authorization before covering specific services, such as surgeries, MRIs, high-cost prescriptions, or durable medical equipment. Prior approval means the insurer wants to review medical necessity before agreeing to pay.

Why This Happens:

• Your provider may not have submitted the authorization.
• The request lacked the required documentation.
• The service was urgent and performed before authorization could be obtained.

What You Can Do:

• Ask for a Retroactive Review: For urgent or unplanned procedures, your provider may submit a retroactive request.
• Submit an Appeal: Include the original denial, a letter of medical necessity from your doctor, and any clinical evidence supporting urgency.
• Plan Type Tip: ACA-compliant and non-ERISA plans generally allow expedited internal appeals if delay could harm your health. Under ERISA plans, you may also ask for an urgent review; however, ensure that you comply with all internal timelines.

2. Out-of-Network Provider

Insurers restrict coverage to a network of approved providers. If you see someone outside this network, you may be left with a hefty bill or a denial of coverage.

Why This Happens:

• The provider wasn’t listed in the insurer’s directory.
• An out-of-network facility provided emergency care.
• The insurer believes an in-network alternative was available.

What You Can Do:

• Request an In-Network Exception: Especially if no suitable in-network provider is available within a reasonable geographic area.
• Appeal Based on Access Issues: Include a physician’s letter explaining why the care couldn’t be delayed or replaced.
• Plan Type Tip: ACA plans often include external review rights for disputes related to network access. ERISA plans vary; check your Summary Plan Description (SPD) to confirm appeal options.

3. Coding Errors or Incomplete Claims

Every insurance claim must have correct CPT (procedure) and ICD-10 (diagnosis) codes. Even one typo or omission can trigger a denial.

Why This Happens:

• A billing office used incorrect or outdated codes.
• Missing modifiers made the procedure seem unnecessary or experimental.
• The diagnosis didn’t support the procedure.

What You Can Do:

• Ask for a Claim Resubmission: Have your provider’s billing team review the codes for accuracy.
• Include a Letter from the Provider: Explain why the codes used are correct and consistent with your diagnosis.
• Plan Type Tip: Time limits matter. Under ERISA, initial claim deadlines are often shorter, typically within 180 days. Late resubmissions could be barred.

4. Service Not Covered by Your Plan

Some policies exclude services such as fertility treatments, cosmetic procedures, off-label medications, or alternative therapies. Insurers may also consider standard treatments as “experimental.”

Why This Happens:

• The insurer’s internal policy classifies the service as investigational.
• There is no specific coverage language in the plan documents.
• Clinical guidelines differ between providers and insurers.

What You Can Do:

• Check the Summary Plan Description (SPD) or Evidence of Coverage (EOC): Look for the exact language used to deny your claim.
• Submit Supporting Evidence: Include peer-reviewed studies, national guidelines (e.g., NCCN, AHA), and detailed letters from doctors.
• Plan Type Tip: External review rights under the ACA apply to denials of “medical necessity” and “experimental” care. ERISA plans do not have to offer external review, but may do so voluntarily.

5. Missed Filing or Appeal Deadlines

Most insurance plans have strict timelines for submitting claims and appeals. If you miss these windows, even for valid care, your appeal may be rejected automatically.

Why This Happens:

• Deadlines vary by plan and stage (initial claim vs. appeal).
• The denial letter may have been unclear or delayed in its delivery.
• A medical emergency prevented timely filing.

What You Can Do:

• File a Late Appeal with Cause: Explain the delay (e.g., hospitalization, miscommunication) and submit supporting documentation.
• Track and Document Every Step: Use certified mail or secure email to keep proof of submission.
• Plan Type Tip: ERISA plans have hard deadlines (e.g., 180 days for internal appeal). ACA-compliant plans may allow flexibility for good cause.

Know Your Plan Type, And Your Rights

Understanding your plan type is essential to knowing your appeal rights:

• ERISA Plans (Employer-Sponsored): Governed by federal law (29 U.S.C. § 1132). No jury trials. No required external review. Only one internal appeal is generally required. The administrative record is critical.
• ACA Marketplace Plans: Must provide internal and external appeals. Must follow federal timeframes. Expedited reviews apply to urgent cases.
• Private Non-ERISA Plans (e.g., Church Plans, Some Individual Policies): Varies by state. Kentucky and Ohio both require compliance with state appeal deadlines and external review processes.

You Don’t Have to Fight Alone

A denial need not be the end. You have legal rights—and with the right help, you can build a strong, well-documented appeal that challenges the insurer’s decision.

At Appeal Healthcare, we help individuals and families in Kentucky and Ohio take on insurance denials with clarity, strategy, and compassion. Whether you’re dealing with an ERISA plan, an ACA policy, or private insurance, we’ll help you build the strongest possible case.

Let’s Take the Next Step

If your health insurance denied your care, contact us today for a no-obligation consultation. We’ll review your plan type, assess your options, and guide you toward the right next steps, no pressure, just clarity.

Ethics and compliance notes for Ohio and Kentucky

Attorney Advertising. This page provides general information. It is not legal advice and does not create an attorney-client relationship. Every situation is fact-specific. Do not rely on this content without guidance from a lawyer who knows your facts. Past results do not predict future results.

Responsible lawyer and office address: Frank M. Mungo Attorney at Law, 7310 Turfway Road, Suite 550, Florence, Kentucky 41042. Mr. Mungo is licensed in Kentucky and Ohio.