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Insurance denied: not covered by your plan. How to appeal
Your health insurance denied a claim as not covered by your plan. What it means, your deadline, and how to appeal.
Check my letter freeWhat it means
The plan says the service is excluded or not a covered benefit.
What to do
Ask for the exact plan language and compare it with your Summary of Benefits and Coverage.
If the service fits a covered benefit, quote it in your appeal.
Your deadline
Most plans give you 180 days from the denial notice to file an internal appeal. Original Medicare gives 120 days from the Medicare Summary Notice, and Medicare Advantage plans 65 days from their decision. Check the date printed on your letter.
If the plan says no again
After a final denial from a marketplace or employer plan, you can ask for an external review by an independent reviewer within 4 months. If the reviewer decides for you, the plan must pay.
Ask for your claim file
You have the right to receive, free of charge, copies of the documents and the criteria used to decide your claim.
Other denial reasons
- Not medically necessary
- No prior authorization
- Out of network
- Experimental or investigational
- Billing or coding error
- Claim filed too late
- Other insurance (coordination of benefits)
- Coverage not active