Bills and insurance
Insurance denial letter explainer
A denial letter has to state what was refused, why, and how to challenge it, but the wording is formal and the key dates are easy to miss. Add yours below to see those points pulled out and restated.
Explain your insurance denial letter
- 1. Add itDrop a PDF, take a photo or paste the text.
- 2. Check itPersonal details are removed on your device. You approve what is sent.
- 3. Read itSummary, table of results, terms and questions to ask.
The explainer opens on its own page with no adverts and no outside scripts. Your file is read on your device and is never uploaded.
What you get
- The service or claim that was denied, as named in the letter.
- The reason for the denial restated in plain language.
- Appeal options, deadlines and contact details listed as the letter gives them.
- Questions to ask your insurer and your doctor's office.
Reasons and terms you may see
- Not medically necessaryThe insurer says the request did not meet its criteria
- Prior authorization requiredApproval was needed before the service
- Out of networkThe provider is not contracted with your plan
- Not a covered benefitYour plan does not include that service
- Internal appeal and external reviewAsking the insurer to reconsider, then asking an independent body
- Peer-to-peer reviewYour doctor discussing the request with the insurer's doctor
What this tool cannot tell you
MedicDecode restates the letter. It cannot see your policy, cannot say whether the denial is correct and does not give legal advice. Appeal deadlines are strict, so note the dates in your own letter and act on them. Your doctor's office and your insurer's member services can both help with an appeal.
Common questions
What does not medically necessary mean?
It means the insurer decided the request did not meet its own criteria for coverage. It is not a judgement by your doctor, and it is one of the reasons that can be appealed.
How long do I have to appeal?
The letter itself states the deadline and how to appeal. The explanation points out the dates it finds, but always check them against the letter.
What is prior authorization?
Approval that some plans require from the insurer before a service, test or medicine is provided.
Words you may see on this report
Tap a word for its plain-English meaning, an example line and what it does not mean.
- In-Network
In-network means a doctor, hospital or pharmacy has a contract with your insurance plan to provide care at agreed prices.
- Coinsurance
Coinsurance is the percentage of a covered health care cost you pay after meeting your deductible, such as 20 percent of the allowed amount.
- Copay
A copay is a fixed amount you pay for a covered health service or prescription, such as a set fee for each doctor visit.
- CPT Code
A CPT code is a five-character code that describes a medical service or procedure, used on bills and insurance claims in the United States.
- Deductible
A deductible is the amount you pay for covered health care each year before your insurance starts paying its share.
- Explanation of Benefits (EOB)
An explanation of benefits (EOB) is a statement from your insurer showing what was billed, what the plan paid and what you may owe for a claim.
- ICD-10 Code
An ICD-10 code is a letter-and-number code that describes a diagnosis, symptom or reason for care on medical records and bills.
- Out-of-Pocket Maximum
The out-of-pocket maximum is the most you pay for covered, in-network care in a plan year; after that, the plan pays 100 percent of covered services.
- Prior Authorization
Prior authorization is approval your insurer must give before certain treatments, tests or medicines are covered.