What to do when an insurance claim is denied

Read the denial reason first

A denied claim can mean many things: missing information, incorrect coding, eligibility questions, prior authorization issues, out-of-network processing, coordination of benefits, or a service that the plan says is not covered.

The denial reason tells you which office is most likely to know the next step. Without it, calls become longer and easier to misroute.

Assign the next action

Ask the insurer whether the provider needs to submit a corrected claim, send records, add a modifier, update insurance information, or take another specific action. If the insurer needs something from the patient, ask exactly what document is needed and where it should be sent.

Then call the provider with the insurer's instruction and ask whether they can complete that action. Record both sides in the same follow-up log.

• Provider action: corrected claim, records, coding review, authorization documentation.
• Insurer action: reprocessing, claim review, coordination update.
• Patient action: insurance update, consent, appeal form, supporting document.

Watch for deadlines

Claim reprocessing and formal appeals are not the same thing. A provider may be able to correct and resubmit a claim, but an appeal may have a deadline stated in the plan documents or EOB.

If a deadline is mentioned, record the exact date and avoid relying on memory. Billing follow-up becomes much easier when deadlines, promises, and reference numbers live in one place.