How to read a health insurance denial letter
Denial letters are written to be short. These are the parts that matter for an appeal.
General information, not advice about your case. These steps describe what public agencies and consumer groups commonly suggest. They are not legal, medical or insurance advice, and what applies to you depends on your state, plan, insurer and facts. Check your denial notice and plan documents, and consider asking a licensed attorney, your state insurance department, a patient advocate or your doctor before you act. Full disclaimer.
| Look for | Why it matters |
|---|---|
| Date on the notice, and date you received it | Deadlines are counted from receipt (employer plans, Marketplace) or from the notice date (some Medicare and Medicaid steps). Keep the envelope. |
| Reason for denial and any denial code | Non-grandfathered plans must include the denial code and its meaning, and must give diagnosis and treatment codes and meanings on request. |
| Rule, guideline or criteria used | The notice must include it or tell you how to get it. An appeal commonly answers this directly. |
| How to appeal, where to send it, deadline | Follow the plan's steps. An appeal in the wrong place can cost time. |
| External review and help information | Notices for non-grandfathered plans must describe internal appeals, external review and consumer assistance. |
| Type of claim: urgent, before-care (pre-service) or after-care (post-service) | It sets how quickly the plan must decide: 72 hours, 30 days or 60 days for the appeal under the federal rules for group health plans. |
Denial or bill?
An explanation of benefits (EOB) is not a bill and not always a denial. If the EOB says a service was "denied" or "not covered," ask the provider's billing office whether a corrected claim is possible before you appeal. Many denials come from missing information or coding.
Next
Request a written explanation if your letter is vague, or start an appeal letter.
Related guides
- Health insurance denial: first steps
- How to file a health insurance internal appeal
- Prior authorization denied: what to do
- State insurance department directory
Sources
- U.S. Department of Labor (EBSA): Filing a Claim for Your Health or Disability Benefits, last verified 2026-10-20
- U.S. Department of Labor (EBSA): Filing a Claim for Your Health Benefits, last verified 2026-10-20
- HealthCare.gov: Internal appeals, last verified 2026-10-20
- CMS: Coverage Appeals Job Aid, last verified 2026-10-20
Page last reviewed October 20, 2026. Rules change; confirm with your notice, plan documents or the agency pages above.