Getting injured is hard enough. But then you get hit with a denial letter for your ER visit, imaging, physical therapy, or follow-up appointments? It feels like the whole system is working against you.
The good news is that many denials come down to fixable issues like missing information, billing errors, etc. This guide breaks down the most common reasons a health insurance claim denial happens after injury treatment. Also, we will discuss how to appeal so that you get the best shot at getting your claim paid.
TL;DR/Summary
An insurance claim denial means your health plan refused to pay all or part of your injury treatment bill. Common causes include missing prior authorization, out-of-network care, coding errors, lack of medical necessity documentation, or deadlines being missed.
Start by reviewing your EOB and insurance claim denial letter. You can call your insurer for specifics and ask your provider to correct errors. If needed, file an internal appeal (often within 180 days) and request an independent external review.
What is Insurance Claim Denial?
An insurance claim denial is when your health insurer decides it won’t pay for a medical service. You’ll usually learn about the decision through an Explanation of Benefits (EOB) or a formal insurance claim denial letter. The EOB is the insurer’s breakdown of what was billed, what the plan allowed, and what the insurer paid (if anything).
A health insurance claim denial can happen for injury-related care even when you did “everything right.” For example, emergency care may be covered, but follow-up imaging might require prior approval. Or your insurer may need additional clinical notes to confirm why a service was necessary.
Understand that claim denials aren’t rare. In the federal ACA Marketplace, insurers denied 19% of in-network claims and 37% of out-of-network claims in 2023 (about 20% overall). Those numbers don’t represent all plans, but they show why an insurance claim denied notice can happen to anyone.
What Are the Most Common Reasons for Health Insurance Claim Denials?
Denial categories often sound generic, but the underlying reason is usually one of these.
1 Missing prior authorization or referral
Many plans require approval before certain services are covered, especially imaging (MRI/CT), injections, specialist visits, or higher-cost procedures. KFF’s analysis found that lack of prior authorization or referral accounted for a meaningful portion of denials.
This is a big reason why insurance companies deny claims? They treat “no authorization” as a plan-rule failure, even when the care felt urgent to you.
2. Administrative issues and incomplete information
A surprising number of denials happen because the claim wasn’t processed cleanly. Common triggers include:
- Missing accident details or diagnosis codes
- Incorrect patient info (name, DOB, member ID)
- Missing clinical notes
- Duplicate submissions
- Filing after the plan’s deadline (“timely filing”)
In the same KFF dataset, administrative reasons were one of the most commonly reported categories.
3. Out-of-network care
After an injury, you may go wherever you can get care. If the facility or provider is out of network, your plan may deny the claim or pay far less. Sometimes you’re actually in network, but the claim lists the wrong provider tax ID or location. So, it gets processed as out of network.
4. “Not medically necessary” (documentation issue)
“Medical necessity” denials often mean the insurer wants stronger documentation connecting your injury, symptoms, exam findings, and treatment plan. In HealthCare.gov reporting, a smaller share of denials were categorized as medical necessity compared to admin or “other.” But it’s still a common reason people see in real life, especially for imaging, pain procedures, and extended therapy.
5. Service is excluded or benefit limit was reached
Your plan may exclude certain treatments or cap the number of visits (for example, physical therapy limits). KFF’s analysis lists excluded services and benefit limits among reported denial categories.
6. Coverage issues at the time of service
It may happen that the premiums weren’t paid or coverage lapsed. Maybe the wrong plan was billed or coordination-of-benefits wasn’t updated. This way, you can get a health insurance claim denied outcome even if the service would normally be covered.
7. Prior authorization delays can derail care
A lot of injury treatment denials are connected to prior authorization delays and back-and-forth requirements. The AMA’s 2024 physician survey reported that prior authorization often delays necessary care for patients and creates serious burdens. Even when your provider tries to do everything right, there can be denials if paperwork isn’t exactly what the plan expects.
Next Steps if Your Insurance Claim is Denied
When you’re staring at an insurance claim denial, your goal is to move from confusion to a documented plan. Here’s a step-by-step approach that works for most people.
Step 1: Find the “why” in your EOB and denial notice
Start with the EOB and the insurance claim denial letter.
If you don’t understand the language, call the insurer and ask: “What specific documentation or correction would make this payable?”
Step 2: Call the insurer and ask for details in writing
Insurers must tell you why a claim was denied and how to dispute it. When you call, request:
- The exact denial policy/criteria used
- Whether a corrected claim can be resubmitted (sometimes faster than appealing)
- The appeal deadline and where to send it (portal, fax, mail)
Write down the date, time, and representative name.
Step 3: Call the provider’s billing office and ask them to review the claim
Many “denied” claims are fixable through:
- Corrected coding (CPT/ICD-10/modifiers)
- Adding missing documentation
- Correcting provider identifiers
- Resubmitting with accident details if required
This is often the quickest way to reverse an insurance claim denial.
Step 4: Gather your proof packet
Staying prepared makes your appeal stronger and keeps you organized.
Step 4: Consider speaking with a personal injury attorney
If your medical care relates to an injury caused by someone else, it may help to consult a personal injury attorney.
An attorney can look at the bigger picture beyond the health insurance claim denial itself. This includes how your treatment costs should be handled through a personal injury settlement claim, payments, medical liens, etc.
If negotiations don’t move fairly, your attorney can escalate the dispute into formal litigation. They can even use discovery tools to obtain records, challenge defenses, and build a stronger case for settlement/trial.
Step 5: If bills are stacking up, explore other payment options
If a health insurance claim denied decision leaves you facing large balances, it’s smart to protect your finances. Ask your provider about a temporary hold while the appeal is pending, a payment plan, or funding options for plaintiffs.
Another option, especially when your injury is tied to an active personal injury case, is pre-settlement funding. This is a type of funding that gives you access to money before your case settles. This way, you can cover essential expenses while the legal process plays out. It can help relieve pressure to accept a low settlement just to keep up with bills.
At GAIN Servicing, we help plaintiffs access pre-settlement funding so you have financial breathing room during the case. If you’re dealing with an insurance claim denial and medical costs are creating stress, funding can be helpful while your attorney works through next steps.
How to Appeal a Health Insurance Claim Denial Effectively?
If resubmission doesn’t fix it, an appeal is your next move. You usually have two layers: internal appeal (through the insurer) and external review (independent).
File an internal appeal fast and keep it simple
You generally must request an internal appeal within 180 days of receiving the denial notice (timelines can vary by plan type).
Ask for an expedited appeal if your care is urgent
If you need urgent medical help, you may request an external review at the same time as your internal appeal.
If the insurer upholds the denial, request an external review
Under the Affordable Care Act, many plans must offer access to independent external review after internal appeal. CMS explains that consumers can appeal to an outside decision-maker if the insurer upholds its denial.
You typically must request an external review within four months after receiving a final denial notice. The insurer must accept the external reviewer’s decision.
Don’t assume “nobody wins appeals”
People often skip appeals because the process feels intimidating. KFF found that in HealthCare.gov plans, fewer than 1% of denied in-network claims were appealed. Also, insurers upheld the denial 56% of the time in those internal appeals. That’s exactly why a well-documented appeal matters.
If this process feels overwhelming, it can help to bring in the right personal injury and/or health insurance coverage attorney. A strong legal team can spot weak reasoning, organize documentation, manage deadlines, and push the issue through appeals or litigation. This way, you’ll not be fighting a complex system alone.
Final Word
An insurance claim denial for injury treatment can feel like you’ve hit a wall, but it doesn’t mean you’re out of options. Many denials can be challenged by reviewing the denial reason, correcting claim errors and filing an appeal within the deadline.
At the same time, we understand the real-life impact an insurance claim denied notice can create. In real life, medical bills don’t pause, and everyday expenses still show up while you’re trying to heal. That’s where we can help. At GAIN, we support plaintiffs by offering pre-settlement funding. So, you can cover essential costs while your personal injury claim is in progress. This way, you do not need to feel pressured to accept a low settlement.
FAQs
Which companies offer services to review denied health insurance claims?
If your injury case is being handled by a law firm, your attorney is often the best starting point. They can manage medical records, bills, and denial paperwork in a way that supports your claim. Additionally, there are companies like GAIN Servicing who help attorneys review denied health insurance claims by focusing on documentation, billing accuracy, and appeal readiness.
How do I find a lawyer specializing in health insurance claim denials?
Look for a health insurance claim denial attorney with experience in your plan type (employer/ERISA, Marketplace, Medicare Advantage, Medicaid). Start with your state bar’s lawyer referral service to find attorneys who specifically list insurance appeals or healthcare coverage disputes.
What steps should I take after receiving a denied health insurance claim?
After receiving an insurance claim denied notice, review the EOB and denial letter. Call the insurer for the exact reason and fix path and ask your provider to correct/resubmit if it’s an error. Make sure to gather all your documents in one folder. If resubmission doesn’t resolve it, file an internal appeal within the required deadline (often 180 days).
Are there services that negotiate health insurance claim denials on my behalf?
If your denial is tied to an injury claim, it’s often most effective to work through your attorney or legal team. They can align the denial response with the case strategy and communicate with providers and insurers in a documented way.
How do I check the status of my denied insurance claim online?
Most insurers let you track a health insurance claim denied status through your member portal or app. Look for “Claims,” find the claim number from your EOB, and review the denial details and appeal instructions. If the portal is unclear, call member services and ask them to read the denial reason and the next steps.