My Insurance Denied Something: What Do I Do Next?
A denied claim, treatment, prescription, test, or prior authorization doesn't always mean the decision is final. The first step is understanding exactly what was denied, why it was denied, and which process applies to you.
This guide helps patients in Canada and the United States move from denial to a clear next step — without guessing, missing a deadline, or sending an appeal before understanding the reason for the denial.
1. Problem: Your Insurance Said No
Insurance denials can look similar on the surface, but the right response depends on what was denied and why. A denial may involve a claim that's already been submitted, a treatment that hasn't happened yet, a prescription, a prior authorization, a coverage exclusion, network status, medical necessity, eligibility, or missing information.
A claim was denied
Your insurer says it won't pay all or part of a claim for care, a service, a prescription, a procedure, or another covered expense.
Prior authorization was denied
Your insurer won't authorize a treatment, medication, procedure, test, or service before it's provided.
Something was excluded
The insurer says the benefit, service, provider, treatment, or item isn't covered under your plan.
Medical necessity was questioned
The insurer says the requested service or treatment doesn't meet its medical-necessity criteria.
Network or eligibility issue
The denial may involve an out-of-network provider, enrollment, eligibility, coordination of benefits, or another coverage rule.
Information was missing
The insurer may need medical records, clinical notes, documentation, coding information, a referral, or other supporting information.
2. Assess: Find Out What Was Actually Denied
Your first job isn't to write an appeal. Your first job is to build a clear picture of the decision.
Gather these documents
- The denial notice — letter, portal message, explanation of benefits, adverse benefit determination, or other document explaining the decision.
- Your insurance or plan information — member ID, policy or group number, plan name, and the insurer or administrator.
- The claim or authorization information — claim number, authorization number, date of service, requested treatment, prescription, test, procedure, or other service.
- Relevant clinical information — when appropriate, such as a doctor's letter, medical records, clinical notes, treatment history, or documentation supporting the request.
- Your communications — keep copies of emails, letters, portal messages, and notes from calls.
Ask: Why was it denied?
Look for the insurer's stated reason. Don't rely only on a customer-service representative's verbal explanation.
Ask: What exactly was denied?
Identify the service, date, amount, medication, provider, authorization, or benefit involved.
Ask: What is the deadline?
Find the date by which you must request reconsideration, an internal appeal, external review, or another form of review.
The Process Depends on Where Your Coverage Comes From
Canada and the United States don't use one identical insurance-denial system. Before deciding what to do next, identify which country's coverage system and which type of plan made the decision.
Canada: First Identify Whether This Is Public Coverage or Private Insurance
Canada's publicly funded health insurance is administered by the provinces and territories. Coverage decisions involving publicly insured hospital and physician services can therefore be different from a denial by a private or workplace insurance plan.
Private and workplace plans commonly provide additional coverage for things such as prescription drugs, dental care, vision care, physiotherapy, and other services that may not be covered by the provincial or territorial plan.
If a private insurer denies a health or life insurance claim, generally start with the insurer's complaint process and get its final position in writing before moving to the appropriate external complaint or regulatory pathway.
Canada: How to complain about a private insurance decision →
Identify the type of health coverage first
U.S. appeal rights and procedures can vary depending on whether your coverage is an individual or Marketplace plan, an employer plan, Medicare, Medicaid, or another type of coverage.
For many health plans, an internal appeal lets you ask the plan to reconsider a denial. Some situations also allow an external review by an independent reviewer.
Medicare has its own appeal process, so Medicare coverage decisions should be handled through the Medicare-specific procedure described in your decision notice and plan materials.
3. Decide: Which Problem Are You Actually Trying to Fix?
The best next step depends on the reason for the denial. Use this decision guide before sending anything to the insurer.
| If the denial says... | First question to ask | Likely next direction |
|---|---|---|
| Not medically necessary | What clinical criteria did the insurer use, and what evidence supports the treatment? | Gather clinical documentation and determine the applicable appeal or reconsideration process. |
| Not covered / excluded | Does the plan actually exclude the service, or is the denial based on a different rule? | Check the plan wording and request clarification if the reason doesn't match the policy. |
| Out of network | Was the provider required to be in-network, and were there circumstances that affected network access? | Check network rules, exceptions, referrals, authorization, and the plan's appeal procedure. |
| Prior authorization required | Was authorization required before the service, and was it requested correctly? | Determine whether a new authorization, reconsideration, peer review, or appeal is available. |
| Missing information | What exact documentation does the insurer say is missing? | Get the missing information and submit it using the insurer's stated process. |
| Eligibility / coverage ended | Was coverage actually active on the relevant date? | Verify enrollment, effective dates, employer records, or government-program eligibility before challenging the claim. |
| Claim or coding problem | Was the claim submitted correctly, and does the denial match the actual service? | Ask the provider or billing department to review the claim before escalating unnecessarily. |
4. Next Step: Choose the Correct Route
The insurer may have made an error
If the denial appears inconsistent with your plan, authorization, claim information, or supporting documentation, ask for clarification and find out whether the decision can be corrected or reconsidered.
You may need a formal appeal
If the insurer is maintaining the denial, follow the formal appeal or reconsideration instructions in your denial notice and plan documents.
You may need external review
Depending on your country, plan, province, state, and type of denial, an independent external review or complaint process may be available.
5. Act: Build Your Case Before You Submit It
A strong appeal is easier to review when it directly connects the denial reason with the evidence that addresses it.
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Write down the denial reason
Copy the insurer's reason accurately. Don't rewrite it into something that changes its meaning.
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Match evidence to the reason
If the denial concerns medical necessity, the relevant evidence may include clinical documentation. If it concerns authorization, identify the authorization request and decision. If it concerns eligibility, verify the dates and coverage information.
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Ask your healthcare provider for targeted help
Don't just ask your doctor to "appeal everything." Explain the specific denial reason and ask what clinical or administrative information might address it.
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Submit through the correct channel
Follow the instructions in the denial notice. Use the required portal, form, mailing address, fax, or other submission method. Keep a complete copy of everything you send.
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Track the case
Record the submission date, confirmation number, expected response, contact person, and every follow-up conversation.
Insurance Denial Resolution Tool
We're building a dedicated tool to walk you through the insurance-denial process step by step.
The tool will be built around four practical stages:
- Understand your denial
- Build your appeal
- Submit your case
- Track your case
For now: use this page to understand the denial, identify the correct pathway, gather your documents, and figure out what you need to do next.
6. Resolve: What Counts as a Resolution?
Resolution doesn't always mean the insurer immediately pays the claim. The goal is to reach a documented outcome and understand what options remain if the denial continues.
- The denial is reversed: the insurer approves or pays the service or claim.
- The denial is corrected: the insurer identifies an administrative, coding, eligibility, authorization, or documentation problem and reprocesses the claim.
- The denial is upheld: you receive a documented explanation and can determine whether another appeal, external review, complaint, regulator, or other remedy is available.
- The coverage issue is clarified: you learn the service is excluded or outside the plan's coverage and can make a more informed decision about what to do next.
Canada: If the Insurer Still Says No
If your issue involves private or workplace life and health insurance, start with the insurer's internal complaint process. Ask for the insurer's final position in writing. If you remain dissatisfied, an external complaint-resolution organization or provincial/territorial regulator may be the next step, depending on the type of insurance and where you live.
Canada.ca: How to file a complaint with your insurance company →
OmbudService for Life and Health Insurance (OLHI) →
If you believe a publicly funded provincial or territorial health service was improperly denied, or you were charged for a service you believe should have been insured, the appropriate provincial or territorial health authority may be different from a private-insurance complaint.
United States: If the Insurer Still Says No
If your health plan continues to deny a claim or coverage, check your denial notice and plan documents for the next level of review. Depending on the plan, you may have an internal appeal and, where applicable, an external review by an independent reviewer.
HealthCare.gov explains that many health-plan decisions can be challenged through internal appeals, and that external review may be available.
HealthCare.gov: Appealing a health plan decision →
If you have Medicare, use the Medicare appeal process rather than assuming the ordinary commercial-insurance procedure applies.
Medicare.gov: Filing an appeal →
For additional U.S. consumer guidance:
Related Help From The Patient Insider
Once you understand the denial, you may need help with the document, bill, EOB, or related problem connected to the decision.
Health Insurance Coverage Hub
Understand insurance coverage, plan rules, and healthcare coverage problems.
Explore the Health Insurance Coverage Hub →Understand My Medical Bill Charges
Use the medical-bill decision flow when a denial has resulted in a bill you don't understand or believe may be incorrect.
Understand my medical bill →How to Read an EOB
Learn how to identify the service, amount billed, insurer payment, patient responsibility, and denial information shown on an EOB.
Learn how to read an EOB →Common Medical Billing Errors
Check whether a claim or bill problem may involve an administrative or billing error rather than a genuine coverage decision.
Check common billing errors →How to Dispute a Medical Bill
If the insurance issue has become a patient bill dispute, use the separate medical-bill dispute pathway.
Dispute a medical bill →Medical Bills Hub
Return to the broader medical-bills hub for help checking, understanding, disputing, and resolving healthcare charges.
Visit the Medical Bills Hub →Frequently Asked Questions
Does an insurance denial mean I have to pay the bill?
Not necessarily. A denial means the insurer has made a decision about the claim or coverage. Your provider may still bill you, but you should first understand the denial, confirm the amount you actually owe, and determine whether the decision can be corrected, reconsidered, appealed, or reviewed.
Should I appeal every insurance denial?
No. First identify the reason for the denial. Some problems are better handled by correcting missing information, fixing a claim, confirming eligibility, or clarifying coverage. A formal appeal makes more sense when the insurer has made a coverage decision that you believe should be reconsidered.
What if my doctor says the treatment is medically necessary?
Your doctor's opinion can be important evidence, but it doesn't automatically override the insurer's coverage rules. Ask your provider to address the specific reason given in the denial and provide relevant clinical documentation when appropriate.
What if the denial is for something I needed urgently?
Ask immediately whether an expedited or urgent appeal, reconsideration, or review process is available. U.S. rules provide expedited pathways for certain urgent situations, while the applicable process in Canada depends on the type of coverage and decision.
What if I lost the denial letter?
Contact the insurer or plan administrator and request another copy. You need the written decision and its instructions whenever possible, especially because appeal deadlines can run from the date you receive the decision.
Can The Patient Insider appeal the denial for me?
The Patient Insider provides educational information, administrative guidance, tools, scripts, and decision support. We do not act as your insurance company, government agency, lawyer, or healthcare provider. Our upcoming Insurance Denial Resolution Tool will help you organize the process yourself.
You don't have to figure out the denial all at once.
Start with the decision in front of you. Find out what was denied, understand why, identify which rules apply, choose the correct next step, and document what you do.
The goal isn't simply to "fight the insurance company." The goal is to understand the decision well enough to choose the strongest available path toward resolution.