How Denied Claims Crush Patients (and How Advocates Fight Back)

Step-by-step: how to appeal a denied claim

Imagine going through the hassle of finding the right doctor, getting tests done, and finally receiving the treatment you need—only to get a letter in the mail saying your insurance won’t cover any of it. Suddenly, you’re facing thousands of dollars in bills, all because of a missing code, a denied pre-authorization, or some vague excuse like “not medically necessary.”

If your health insurance claim has been denied, you’re not alone—about 15% of medical claims are denied. Fortunately, you have the legal right to appeal, whether you’re dealing with Medicare, Medicare Advantage, or private insurance. Many denials are based on errors, missing paperwork, or miscommunication between providers and insurers—things that can be corrected.

Here’s how to fight back:

Step 1: Read your Explanation of Benefits (EOB)

The first thing to do when your claim is denied is to check the reason. Your EOB (or denial letter) will list one of these common explanations:

• Missing information – A billing code error, a typo, or incomplete documentation.
• Prior authorization not obtained – Some treatments require pre-approval.
• Not medically necessary – The insurer claims the treatment isn’t essential (even if your doctor says otherwise).
• Out-of-network provider – The service was performed by a provider not covered under your plan.

Step 2: Call your insurer and ask for details

‍Before filing a formal appeal, call your insurance provider and ask for a detailed reason for the denial. Sometimes, a simple correction can get the claim reprocessed without a full appeal.

‍Ask these key questions:

• Was this denied due to missing paperwork?
• Can this claim be reprocessed if I provide additional documentation?
• Is there a way to submit prior authorization retroactively?

Step 3: Gather supporting documents

‍For most appeals, you’ll need to submit:

• A letter from your doctor explaining why the treatment is medically necessary.
• Medical records and test results to prove the need for care.
• A corrected claim from your provider if a billing error was the issue.

Step 4: Submit an internal appeal

‍All insurers, including Medicare and Medicare Advantage, must offer an internal appeal process. Submit your appeal in writing along with supporting documentation.

‍Deadlines:

• Medicare & Medicare Advantage: 60 days from denial.
• Private insurance: 60-180 days (varies by provider).

Step 5: Request an external review if needed

‍If your internal appeal is denied, you can take it to an independent third party. This is called an external review, and the insurer must follow the final decision.

‍Fast-track appeals: If your health is at risk, you can request an expedited review, which must be completed in 72 hours.

How insurance companies make appeals difficult

‍Even though appeals can work, insurance companies make them as frustrating as possible. They count on you giving up. Expect to deal with:

• Long hold times, transferred calls, and vague answers.
• Confusing paperwork that seems designed to trip you up.
• Denials that contradict what a previous rep told you.
• Delays—while your health deteriorates.

This is why so many people don’t appeal—and why having an advocate makes all the difference.

What advocates do—so you don’t have to

‍Now you’ve seen the steps of appealing a denied claim: Reviewing your Explanation of Benefits, gathering medical records, writing a formal appeal, resubmitting paperwork, making endless phone calls, following up, escalating the case—and often doing all of this while you’re managing a chronic condition or recovering from surgery.

It’s a lot to take on alone–and insurance companies hope you’ll give up. A health advocate changes everything. Instead of spending hours—sometimes weeks—battling the system, you can hand it off to someone who knows exactly how to get results.‍

What a Solace advocate will do for you

1. Review your EOB and denial letter, pinpointing the exact reason your claim was denied, so there’s no guesswork.
2. Talk to the insurance company on your behalf – No more spending hours on hold, getting transferred to the wrong department, or repeating yourself to different reps.
3. Gather medical records and supporting documents – Tracking down doctors’ notes, lab results, and corrected claim forms so you don’t have to.
4. Write and submit a professional appeal – Advocates know the right medical and legal terminology that makes insurers take an appeal seriously.
5. Follow up relentlessly – If the insurer drags their feet, advocates keep pushing, making sure nothing “gets lost in the system.”
6. Escalate your case if needed – If a regular appeal fails, they take it to an external review board or state regulators.

Why this matters

‍Maybe you could do all of this on your own. But should you have to? The reality is, most people don’t have the time, knowledge, or energy to go head-to-head with an insurance company.

• Do you know how to word an appeal so it has the highest chance of approval?
• Do you have hours to spend tracking down paperwork and sitting on hold?
• Do you feel confident escalating your case to an external review or state agency?

This is why most people walk away. Not because they’re wrong, but because they’re exhausted. An advocate doesn’t just take over the process—they give you peace of mind. While you focus on your health, they focus on making sure you get the coverage you’re entitled to.

And in many cases, having an advocate means the difference between a crushing bill and an approved claim.

Next steps: Let an advocate take this off your plate

• Your time matters.
• Your health matters.
• And you shouldn’t have to fight the system alone.

If you’ve been denied care, get an advocate on your side today.

Walter’s Story

‍Walter* is a real Solace patient. After emergency surgery for renal failure and a month in the hospital, he was sent to a skilled nursing facility to recover. But instead of improving, he got worse—neglect led to bedsores, infections, and new complications.

Then his insurance decided they’d paid enough. The facility gave him 24 hours’ notice before kicking him out. His wife, Lisa*, a nurse, knew how the system worked, but even she was drowning.

She needed in-home nursing care, medical equipment, and transportation—all denied by insurance. Instead, they offered one option: hospice care.

But Walter wasn’t dying. Yet hospice would be covered, while the care he actually needed wouldn’t be.

That’s when Lisa enlisted the help of a Solace advocate.

Walter's advocate, Molly, dug into his records and uncovered the truth: His insurer had ignored its own guidelines. They were using hospice as a loophole to avoid paying for real care.

The advocate escalated the appeal, contacted the insurance company’s compliance team, and got his case reviewed immediately. Within days, Walter was approved for in-home nursing care, medical equipment, and rehab.

This is why fighting back matters. But it shouldn’t be something you have to do alone.

‍Name changed for privacy

FAQs: Common Questions About Denied Claims

Why was my claim denied?
Common reasons include clerical errors, missing prior authorization, and vague “not medically necessary” determinations. Sometimes, insurance companies use these as excuses to delay or deny payment.

How do I appeal a denied claim?
Start with an internal appeal through your insurance company. If they deny it again, request an external review, which forces an independent party to decide.

How long do I have to appeal?
Most insurers, including Medicare, allow 60 to 180 days to file an appeal after a denial. Expedited appeals are available for urgent cases.

What if my insurer refuses to reconsider?
An external review can force them to pay if the independent reviewer rules in your favor. This decision is legally binding.

Can an advocate really help?
Yes. A Solace advocate knows the system inside and out, handling the appeal process, fighting denials, and making sure you don’t have to navigate it alone.

Next steps: Let an advocate take your appeal off your plate

• Your care matters.
• Your life matters.
• And you deserve an advocate who won’t let the system win.

Need help with a denied claim?

‍If you’ve been denied care, don’t wait—Solace advocates are here to fight for you. Get help today.