Having a claim denied is frustrating — but it’s not necessarily the final word. You have the right to appeal denied claims, and many initial denials are overturned on appeal. Here’s how the process works.
Why Claims Get Denied
Common reasons for claim denials include:
- Service not covered by your plan
- Provider was out-of-network
- Prior authorization wasn’t obtained
- The claim was filed as medically unnecessary
- Administrative errors (wrong codes, missing information)
- Service was excluded as related to a pre-existing condition (rare in ACA plans)
Step 1: Understand the Denial
Your insurance company must provide a written explanation of the denial, including the specific reason and the plan provision relied upon. Read this carefully — the denial reason determines your appeal strategy.
Step 2: File an Internal Appeal
All ACA-compliant plans are required to offer an internal appeals process. You must file an internal appeal before pursuing external review. You generally have 180 days from receiving the denial notice to file.
Your appeal should include:
- A written appeal letter explaining why the denial was incorrect
- Supporting documentation from your doctor (medical necessity letter, clinical notes)
- Any relevant clinical guidelines or peer-reviewed literature supporting the service
Step 3: Request External Review
If the internal appeal is denied, you have the right to request external review by an independent organization. The insurer must comply with the external reviewer’s decision. External reviewers overturn internal denials surprisingly often — especially for medical necessity disputes.
Urgent Care Expedited Appeals
If the denial involves urgent care and a delay would harm your health, you can request an expedited appeal that must be resolved within 72 hours.
State Resources
New Jersey has a Department of Banking and Insurance (DOBI) that handles insurance complaints and can assist with appeals that aren’t resolved through the standard process.
Dealing with a denied claim? Garden State Benefits advocates for clients through the appeals process — it’s part of our year-round service.