How to Appeal a Denied Health Insurance Claim

You can often fight back, whether you're on Medicare, you're insured through an employer, or you buy your own health insurance

By Lisa L. Gill
Investigative Reporter

May 5, 2022

Gavel cut out of piece of paper on green background

Did you recently get a letter from your insurer denying coverage for a test, drug, or other healthcare treatment?

If so, you’re hardly alone, whether you get insurance through your employer, buy it on your own, or are on Medicare. One recent study, for example, found that 17 percent of claims from people insured through an Affordable Care Act marketplace plan were denied in 2018. Another study, of people covered through a large Medicare Advantage insurer, found that nearly a third had at least one claim denied over a one-year period. Those denials can leave you on the hook for big medical bills..

But you don’t have to take it lying down, says Caitlin Donovan, a health policy expert at the Patient Advocate Foundation. She notes that there are steps you can take to fight those denials, regardless of where you get your health insurance. If you sought preauthorization for a healthcare service and were denied, you can appeal that decision, too.

First off, mistakes can happen at multiple points in the claim filing or preauthorization process, so phone your insurer to make sure the decision was not made in error. If it was not, ask to speak to the reviewer behind the decision and request an explanation. Keep notes, because you’ll need this information in writing later, Donovan says.

See our special report, "How to Lower Your Medical Bills."

Editor’s Note: This article also appeared in the June 2022 issue of Consumer Reports magazine.

Lisa L. Gill

Lisa L. Gill is an award-winning investigative reporter. She has been at Consumer Reports since 2008, covering health and food safety—heavy metals in the food supply and foodborne illness—plus healthcare and prescription drug costs, medical debt, and credit scores. Lisa also testified before Congress and the Food and Drug Administration about her work on drug costs and drug safety. She lives in a DIY tiny home, where she gardens during the day and stargazes the Milky Way at night.