A denied claim can feel final, but it usually isn't — many denials come down to a paperwork or coding issue rather than the treatment genuinely falling outside your coverage, and a fair number get reversed once that's addressed.
The most common reasons claims get denied
- Missing or incomplete information on the initial claim submission
- A procedure code that doesn't clearly match the documented reason for treatment
- The service falling under a waiting period your plan hasn't cleared yet
- Treatment considered "not medically necessary" by the insurer's own review criteria
- The annual maximum already being reached for the year
The first thing to do
Read the denial reason carefully on your EOB — it's usually a short code or phrase that points to a specific issue. Many denials are administrative rather than a genuine coverage exclusion, which means the fix might be as simple as resubmitting with additional documentation.
How our office can help
- Reviewing the denial reason and confirming whether the code or documentation submitted matches the treatment performed
- Resubmitting a claim with additional clinical notes, X-rays, or photos if the initial submission was incomplete
- Writing a letter of medical necessity if the denial was based on the insurer questioning whether treatment was needed
Filing an appeal
If a resubmission doesn't resolve it, most plans have a formal appeal process with a specific window (often 90 days to a year) to file. An appeal typically requires a written request along with supporting clinical documentation, and can go through one or two levels of review before a final decision.
When a denial is final
Some denials are legitimate — a plan may simply not cover cosmetic procedures, or a service may genuinely fall outside your plan's benefits regardless of documentation. In those cases, we can talk through financing or membership options to help manage the cost directly.
If you receive a denial, bring it to our front desk before assuming it's final — we handle these regularly and can often tell right away whether it's worth pursuing further.
Bring any denial to our front desk before assuming it's final — see our insurance page for the plans we work with directly.
