How to Read and Understand an Insurance Denial Letter

Key Sections of a Denial Letter

1. Denial Reason

The most important section. Look for:

• Specific clinical criteria not met
• Missing documentation
• Non-covered benefit
• Medical necessity not established
• Coding or billing errors

2. Appeal Rights

Federal law requires your denial letter to include:

• How to file an appeal
• Deadline for filing
• Where to send the appeal
• Right to external review
• How to request expedited review

3. Clinical Criteria Used

The letter should reference:

• Which policy or guideline was applied
• What criteria you didn't meet
• What additional information or treatment is needed

4. Contact Information

Note these details:

• Claims department phone number
• Medical director or reviewer name
• Appeal submission address/fax
• Member services number

What to Do After Reading

1. Identify the EXACT denial reason — this determines your appeal strategy
2. Note ALL deadlines — set calendar reminders immediately
3. Request your complete claim file — you have the right to all documents
4. Contact your doctor — share the denial reason so they can address it