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How to read a health insurance denial letter

Denial letters are written to be short. These are the parts that matter for an appeal.

Look for	Why it matters
Date on the notice, and date you received it	Deadlines are counted from receipt (employer plans, Marketplace) or from the notice date (some Medicare and Medicaid steps). Keep the envelope.
Reason for denial and any denial code	Non-grandfathered plans must include the denial code and its meaning, and must give diagnosis and treatment codes and meanings on request.
Rule, guideline or criteria used	The notice must include it or tell you how to get it. Your appeal should answer this directly.
How to appeal, where to send it, deadline	Follow the plan's steps. An appeal in the wrong place can cost time.
External review and help information	Notices for non-grandfathered plans must describe internal appeals, external review and consumer assistance.
Type of claim: urgent, before-care (pre-service) or after-care (post-service)	It sets how quickly the plan must decide: 72 hours, 30 days or 60 days for the appeal under the federal rules for group health plans.

Denial or bill?

An explanation of benefits (EOB) is not a bill and not always a denial. If the EOB says a service was "denied" or "not covered," ask the provider's billing office whether a corrected claim is possible before you appeal. Many denials come from missing information or coding.

Next

Request a written explanation if your letter is vague, or start an appeal letter.