18 steps across 4 sections

1. Understanding Why Insurers Deny Claims

Not medically necessary Insurer's medical reviewer disagrees with your doctor's treatment recommendation
Out-of-network provider Service performed by a provider not in your plan's network
Prior authorization missing Treatment required pre-approval that wasn't obtained
Coding errors Incorrect CPT/ICD-10 codes submitted by provider's billing department
Benefit exclusion Service not covered under your specific plan (cosmetic, experimental, etc.)
Timely filing Claim submitted after the filing deadline (typically 90-180 days)

2. Insurance Literacy Points

EOB vs. bill An Explanation of Benefits (EOB) is NOT a bill — read it carefully to understand what was covered and why
In-network vs. out-of-network Understand your plan type (HMO, PPO, EPO) and how it affects coverage for denied claims
No Surprises Act (2022) Protects against surprise bills from out-of-network providers at in-network facilities — if your claim was denied on this basis, you have federal protections
State insurance departments Every state has a Department of Insurance that accepts complaints about unfair claim denials — this is separate from the appeal process and can apply pressure
Bad faith angle If an insurer repeatedly denies valid claims or acts unreasonably, this may constitute insurance bad faith (see topic #0310)

Internal appeal Typically must be filed within 180 days of denial
Urgent care appeals Insurer must respond within 72 hours
Standard appeals Insurer must respond within 30 days (pre-service) or 60 days (post-service)
External review Available after exhausting internal appeals; independent third party reviews the decision
ACA protections All marketplace and employer plans must offer both internal and external appeal rights

Topic #0310 (Insurance Bad Faith) If your insurer's denial pattern appears unreasonable or systematic
Topic #0348 (Full Appeal Guide) Complete step-by-step appeal process, letter templates, and escalation strategies