Why health insurers deny claims
Every denial has a category, and each category is beaten differently. These are the reasons insurers reported for 61,862,509 denied claims.
| Reason | Claims | Share |
|---|---|---|
| Other reasons | 20,935,723 | 33.8% |
| Administrative reason | 11,430,778 | 18.5% |
| Service excluded from the plan | 10,590,967 | 17.1% |
| Benefit limit reached | 5,518,521 | 8.9% |
| Referral required | 4,534,420 | 7.3% |
| Provider out of network | 3,450,521 | 5.6% |
| Not medically necessary | 2,819,765 | 4.6% |
| Member not covered | 2,540,844 | 4.1% |
| Experimental or investigational | 40,970 | 0.1% |
Find yours on the denial letter — it will use one of these categories or close to it. Then read the page for that reason: the argument that works is different for each.
This page presents federal statistics and a general description of appeal rights created by federal law. It is not legal, medical, or insurance advice, and no outcome is guaranteed. Your denial letter and plan documents govern your specific case. Free help is available from your state's Consumer Assistance Program and from the federal Marketplace at HealthCare.gov.