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The law requires insurers to be transparent about their decision-making. If you receive a denial, follow these specific steps to protect your health and your finances.

  • 1. Request the "Explanation of Benefits" (EOB) Before fighting, ensure the denial wasn't just a typo or a clerical error. Check the "Reason Code" on your EOB for the exact cause of the rejection.
  • 2. Initiate an Internal Appeal Write a formal letter including your Group/Member ID, the specific procedure, and why you believe the policy language supports coverage. Ask for a "Full and Fair Review."
  • 3. Demand a Peer-to-Peer Review If the denial is for "Medical Necessity," have your doctor schedule a call with the insurance company's medical director to discuss the clinical evidence directly.
  • 4. External Independent Review If internal appeals fail, you are legally entitled to a review by an outside medical expert. Their decision is final and overrides the insurance company.
The Paper Trail: Keep a log of every phone call. Record the date, the name of the representative, their employee ID number, and exactly what they told you. In a dispute, your detailed records are often more credible than the insurer's automated notes.

Finding Professional Help

If you reach an impasse, contact your State Insurance Department to lobby your case. They oversee consumer protection and can investigate if the insurer is acting in bad faith.

Click here for a list of State Insurance Regulators