When Health Insurance Says "No": A Free Resource to Help You with Denials

When Health Insurance Says "No": A Free Resource to Help You with Denials

From your AFA EAP 800-424-24060

Did you Know That:

• Approximately one in three insured adults reported that their health plan denied coverage for a health care service within the previous two years. (Kaiser Family Foundation (KFF) survey)
• Plans sold through Healthcare.gov denied 19% of all in-network claims submitted in 2024—almost one out of every five claims.
• Those with employer-sponsored insurance reported slightly higher denial rates than through Healthcare.gov  
• More than 36% of denied claims were categorized simply as "other reason not listed," Other common reasons included administrative errors, excluded services, lack of prior authorization, coverage eligibility issues, and benefit limits.
• Fewer than 1% of denied claims are formally appealed, despite studies showing that 40% to 75% of appealed denials are ultimately overturned.

The good news is that you are not powerless. If you receive a denial, carefully review the explanation of benefits, contact your insurance company for clarification, and ask your health care provider for assistance if needed. Many denials result from administrative issues that can be corrected. Most importantly, do not assume that a denial is final. Filing an appeal may take time, but it can significantly increase the likelihood of receiving coverage for medically necessary care. Before submitting an appeal, request the notes and documents your insurer used when deciding to deny you coverage. ProPublica’s free on-line Claim File Helper will help you customize a letter specifically for getting these records.

When it comes to health insurance denials, persistence often pays off.