Insurance Denials,
successfully appealed.
Health insurance companies deny millions of valid claims every year — counting on patients not to appeal. Our AI Legal Nerds help you understand why your claim was denied, build a compelling appeal, and fight for the coverage you paid for.
Why Insurance Companies Deny Claims
Understanding why your claim was denied is the first step to winning your appeal. Most denials fall into a handful of categories — and most can be successfully appealed.
Not Medically Necessary
The most common denial reason. The insurer claims the treatment is not medically necessary based on their clinical criteria. A strong appeal includes detailed physician documentation explaining why the treatment is essential for your specific condition.
Prior Authorization Denied
Many treatments require pre-approval. Denials often occur when the wrong codes are used or when clinical documentation is incomplete. Our AI helps you identify what additional information the insurer needs.
Out of Network
Claims denied because the provider was out of network. In some cases — especially emergencies or when no in-network provider was available — you have strong grounds to appeal for in-network rates.
Experimental or Investigational
Insurers sometimes deny coverage for treatments they classify as experimental — even when those treatments are standard of care. Our AI helps you find clinical evidence and professional guidelines supporting your treatment.
Filing Deadline Missed
Claims submitted after the insurer's filing deadline. Some deadlines can be waived with proper documentation showing good cause for late filing. Our AI analyzes your situation for waiver eligibility.
Excluded Service
The service is listed as excluded in your plan documents. These are the hardest denials to appeal — but errors in applying exclusions, state mandates, and mental health parity laws may override exclusions in certain circumstances.
The Appeals Process
Internal Appeal
File within 180 days of denialYour first step is always an internal appeal to the insurance company. You have the right to a full review by someone not involved in the original denial decision. Submit all supporting medical documentation, physician letters, and clinical guidelines supporting your treatment.
Expedited Appeal
For urgent situations — decision within 72 hoursIf your health is at serious risk, you can request an expedited appeal. The insurer must respond within 72 hours. Our AI helps you document the urgency of your situation to qualify for expedited review.
External Independent Review
After internal appeal is exhaustedIf your internal appeal is denied, you have the right to an independent external review by a neutral third party. External reviewers overturn insurer decisions approximately 40% of the time. This right is guaranteed by the ACA for most plans.
State Insurance Commissioner
File complaint at any timeFile a complaint with your state insurance commissioner if the insurer violated state insurance laws, failed to follow proper claims procedures, or engaged in bad faith denial practices. State regulators have enforcement power over insurance companies.
Your denial is not final
Insurance companies count on you not appealing. Get expert AI guidance to build a compelling appeal and fight for the coverage you paid for.