Appeal Library
Denial Reasons
Find guidance based on the reason shown on your denial letter or explanation of benefits.
Popular Denial Reasons
- Medical Necessity
A medical necessity denial means a health plan decided a service did not meet its clinical policy criteria. Learn what the denial does and does not establish.
- Prior Authorization Denied
A prior authorization denial means the plan reviewed a proposed treatment and decided it does not meet coverage criteria. Learn the member and provider paths before you appeal.
- Out-of-Network
An out-of-network denial can mean voluntary out-of-network care, a network gap, or a directory error. Learn which fact patterns can qualify for an appeal.
- Missing Referral
A referral and prior authorization are not the same. Learn what records can support a missing-referral dispute and when claim correction may be needed.
- Experimental or Investigational
An experimental or investigational denial means a plan considers a treatment unproven or not yet approved for your specific condition. Learn what evidence the appeal process generally needs.
- Benefit Exclusion
A benefit exclusion means the plan document says a service is not covered, regardless of medical necessity. Learn when an exclusion may still be worth challenging.
- Coding or Claim-Processing Error
A coding or claim-processing denial is usually a billing-form problem, not a coverage decision. Learn what the provider needs to fix and how to protect your own appeal deadline.
All Denial Reasons
- Missing Referral
A referral and prior authorization are not the same. Learn what records can support a missing-referral dispute and when claim correction may be needed.
- Timely Filing
A timely-filing denial turns on dates, submission records, rejections, corrections, and plan rules. Learn what evidence can support reprocessing or an appeal.
- Surprise or Emergency Billing
Federal law protects many consumers from out-of-network emergency bills and prior-authorization requirements. Learn how to separate the insurance claim from the provider bill.
- Prior Authorization Denied
A prior authorization denial means the plan reviewed a proposed treatment and decided it does not meet coverage criteria. Learn the member and provider paths before you appeal.
- Medical Necessity
A medical necessity denial means a health plan decided a service did not meet its clinical policy criteria. Learn what the denial does and does not establish.
- Experimental or Investigational
An experimental or investigational denial means a plan considers a treatment unproven or not yet approved for your specific condition. Learn what evidence the appeal process generally needs.
- Out-of-Network
An out-of-network denial can mean voluntary out-of-network care, a network gap, or a directory error. Learn which fact patterns can qualify for an appeal.
- Benefit Exclusion
A benefit exclusion means the plan document says a service is not covered, regardless of medical necessity. Learn when an exclusion may still be worth challenging.
- Coding or Claim-Processing Error
A coding or claim-processing denial is usually a billing-form problem, not a coverage decision. Learn what the provider needs to fix and how to protect your own appeal deadline.
- Not Medically Necessary (Imaging)
Overturn medical necessity denials for MRIs, CTs, and PET scans. Learn how to counter automated peer clinical guidelines.
- Prior Authorization Missing
Did your insurer deny coverage for a missed prior authorization? Learn the steps to secure a retroactive clinical approval.
- Claim Code CO-50 (Imaging)
What is claim adjustment code CO-50 on your EOB? Learn how to dispute medical necessity determinations for high-tech imaging.
- Claim Code CO-197
Disputed EOB code CO-197? Learn how to file an administrative appeal for missing notification, precertification, or authorization.
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