Insurance denied your claim and the provider is billing you
Why was the claim denied?
A denial is not always final, and it is not always about your care. Some denials come from simple mistakes, such as a missing referral number, a coding problem or a wrong policy ID. Others involve plan rules, such as a service the plan considers not covered or not medically necessary.
Your EOB should print a reason. Start there. The answer decides whether you need the provider to fix and resubmit the claim, or you need to appeal the plan's decision.
What are the common denial reasons?
The wording differs by insurer, but these patterns come up often.
- Missing information or a clerical error that the provider can correct.
- Coding or billing mistakes, such as a mismatched date or a wrong code.
- Prior authorization required but not obtained.
- Out-of-network status, which may or may not be allowed to affect your costs.
- A plan determination that the service was not medically necessary.
- A service the plan treats as excluded from coverage.
What should you ask the provider to do?
Call the provider's billing office and ask whether the denial was a billing error that can be fixed with a corrected claim. Ask them to place your account on hold while you pursue the claim, and to confirm that in writing.
If the denial was about medical necessity, ask your doctor's office for a letter explaining why the care was needed. Providers sometimes file their own appeals, so ask whether they will.
How does the appeal process work?
Insured patients can appeal a denied claim through the plan's internal appeal and may then request independent external review. Employer plans are also governed by ERISA claims procedures (29 U.S.C. § 1133). The deadline is printed on your denial notice or EOB. Many plans allow roughly six months, but check yours.
Write a clear appeal that includes your member ID, claim number, date of service, the denial reason and why you disagree. Attach the EOB, supporting records and any doctor letter. Send it by a method that gives you proof of delivery.
What should you do about the bill in the meantime?
Do not ignore it. Dispute the bill in writing, explain that the claim is under appeal, and ask for a hold. Many providers and collectors expect disputes within a short window printed on the bill, so act promptly and keep proof of when you wrote.
Medical Bill Dispute Pro can generate a formal letter to the provider from your answers, including the denial and your appeal status. Review it before sending, and consider a billing advocate or attorney for complicated denials.
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Frequently asked questions
Do I have to pay the provider if my insurance denied the claim?
Not automatically. First find out why it was denied, because some denials are billing errors the provider can correct, and others can be appealed. Ask the provider to hold your account while you appeal, get that agreement in writing, and keep a record of every call and letter.
How long do I have to appeal a denied claim?
The deadline is printed on your denial notice or EOB. Many plans allow roughly six months, but check yours. Do not rely on a number from a general article. If the deadline is close, file the appeal first and gather additional records afterward when your plan allows it.
What is external review?
External review is an independent review of a denial by someone outside your insurance company. After the plan's internal appeal, you may be able to request it. HealthCare.gov explains the general process, and your denial notice should describe how to ask for external review under your plan.
Can I ask my doctor to help with the appeal?
Yes, and it often helps. Your doctor's office can write a letter describing why the service was needed, supply records and sometimes appeal directly. Ask them early, because it can take time. Send the letter with your appeal and keep a copy for your own file.
Where do I complain if my insurer will not respond?
Complaints about insurers go to your state insurance department, and the NAIC website can help you find it. For employer plans, ERISA procedures may also apply. Keep a timeline of what you sent and when, which makes any complaint stronger.
Sources and further reading
- HealthCare.gov: Appealing an insurance company decision
- ERISA claims procedures, 29 U.S.C. § 1133
- NAIC state regulator map
Related guides
Not legal or medical advice. Medical Bill Dispute Pro is a software tool that helps you prepare billing dispute letters. It is not a law firm, does not provide legal advice, and cannot guarantee any outcome. Laws and rules change and vary by plan and state; verify important details with the sources linked above, your insurer, or a qualified professional.