Health Insurance Denied Your Claim? Here's What to Do Next
By Christy Koraiban, RN BSN IBCLC | Every Baby Feeds
You open a letter from your health insurance company and discover that a claim has been denied. Now what?
Whether it's a specialist appointment, medical testing, a prescription, or care for your child, insurance denials can be incredibly frustrating. But here's something important to remember:
A denied claim doesn't always mean you're responsible for the bill, and it doesn't necessarily mean the decision is final.
Understanding why your claim was denied is the first step toward figuring out what to do next.
Step 1: Start With Your Explanation of Benefits (EOB)
Before making phone calls or paying a bill, take a look at your Explanation of Benefits (EOB).
An EOB is a statement from your insurance company that explains how a medical claim was processed. It typically includes:
What services were billed
How much your healthcare provider charged
What your insurance covered or denied
Why a claim may have been denied
What your insurance company says you may owe
An EOB is not a bill! The amount listed as your responsibility may not reflect what you ultimately owe.
Look for the denial reason or explanation code. This will help you determine your next steps.
Three Common Reasons Health Insurance Claims Get Denied
1. Billing or Documentation Issues
Sometimes a claim is denied because of an issue with how the service was billed or documented.
For example, your healthcare provider may have submitted an incorrect billing code, omitted important information, or failed to include documentation required by your insurance company.
What can you do?
Start by contacting your provider's billing department. Ask whether the claim needs to be corrected, resubmitted, or supported with additional documentation.
Sometimes a relatively simple correction can resolve the issue.
2. Additional Medical Information Is Needed
Your insurance company may require more information before determining whether a service meets its coverage requirements.
This might include:
Medical records supporting the need for a service
Results from previous laboratory testing or diagnostic studies
Documentation of treatments or medications already tried
Additional information supporting medical necessity
What can you do?
Contact your insurance company and ask exactly what information is needed.
Then work with your healthcare provider to determine whether the requested documentation can be submitted or whether another review process is appropriate.
If your insurance requires you to try another treatment or medication first, discuss that requirement with your healthcare provider before making any changes to your care.
3. Your Healthcare Provider Is Out of Network
Another common reason for insurance denials is receiving care from a provider who isn't contracted with your insurance company.
Depending on your plan, you may still have options.
Some insurance plans include out-of-network benefits that allow you to submit a superbill for possible reimbursement.
A superbill is an itemized document from your healthcare provider that includes the information your insurance company may need to process an out-of-network claim.
What can you do?
Contact your insurance company to find out whether your plan includes out-of-network benefits and whether the service is eligible for reimbursement.
Ask about submission requirements, deductibles, and deadlines.
Remember, submitting a superbill doesn't guarantee reimbursement, and not all insurance plans offer out-of-network coverage.
What If Your Claim Is Still Denied?
If you've reviewed the denial and attempted to resolve the issue, you may have the right to appeal the insurance company's decision.
An internal appeal asks your insurance company to reconsider its determination. Depending on your plan and circumstances, an independent external review may also be available.
Be sure to ask about appeal deadlines and documentation requirements.
If the denial involves urgent or medically necessary care, talk with your healthcare provider and insurer about whether an expedited review is available.
How Can a Healthcare Navigator Help?
If you're feeling overwhelmed by the process, you don't have to figure everything out on your own.
At Every Baby Feeds, healthcare navigation is about providing practical, individualized support to help families understand their healthcare options and take the next steps.
As a Registered Nurse (RN, BSN) and International Board Certified Lactation Consultant (IBCLC), I can help you:
Understand your insurance denial. We can review your EOB together, identify the reason for the denial, and determine what questions need to be answered.
Communicate with your insurance company. I can help you call your insurer, ask questions about coverage, and clarify what information is needed.
Work with your healthcare provider. I can help you draft messages requesting medical records, additional documentation, or clarification about billing.
Submit a superbill. If your plan allows out-of-network claims, I can help you organize the information and navigate the submission process.
Understand your appeal options. I can help you identify applicable next steps, organize documentation, and prepare questions about the appeals process.
Healthcare navigation doesn't mean I can guarantee that an insurance company will overturn a denial. It means you have someone helping you understand the process, communicate with the right people, and advocate for your family's needs.
You Don't Have to Navigate Healthcare Alone
Healthcare can be complicated, especially when you're already managing the demands of parenting and caring for your family.
Whether you're dealing with a denied insurance claim, trying to understand your benefits, or struggling to coordinate care, you deserve to understand your options.
Every Baby Feeds offers healthcare navigation support for families in North County San Diego and beyond through virtual sessions.
Ready for some help? Click HERE for scheduling options
— Christy Koraiban, RN BSN LC | Every Baby Feeds | Lactation Support, Education, Healthcare Navigation | North County San Diego
Disclaimer: This article is for general educational purposes and does not constitute individualized medical, legal, or insurance advice. Coverage, appeal rights, and reimbursement requirements vary by plan and circumstances. Always confirm specific requirements with your insurer and healthcare providers.