The short answer: read the explanation of benefits to find the reason, then call us at (480) 934-3890 before you pay or argue. Some denials are a billing or paperwork problem that the doctor's office can fix and resubmit. Others need you to ask the carrier to reconsider, which is called an appeal. The denial notice tells you how to appeal and by when.
Step 1: Read the explanation of benefits
The explanation of benefits, often called the EOB, is the carrier's statement of what happened to a claim: what the provider billed, what the plan allowed, what it paid, and what is left for you. It is not a bill. On a denied claim, it also shows a reason, often as a short code with a note explaining it.
Write down the date of service, the claim number and the reason. You will need all three for every call that follows.
Step 2: Match the reason to a cause
- A billing or paperwork problem. A wrong code, a missing detail, or a name or date that does not match. These are often fixed by the doctor's office resubmitting the claim.
- Pre-authorization was needed. Some plans require approval before certain services, such as outpatient surgery. The plan details say which ones.
- The provider was out of network. Networks change, which is why we check your doctors by name at enrollment.
- The service is not covered, or a cap was reached. A limited medical plan, for example, pays set amounts up to a cap. How limited medical pays.
- Coverage was not active on that date. Applied is not the same as covered. When new coverage starts.
Step 3: Call us first
Call us at (480) 934-3890 for anything you are unsure about. That is what a small agency is for. We stay on your file after you enroll, so bring the EOB and the bill, and we will help you work out what the denial actually says and who to call next.
Step 4: Call the doctor's office and the carrier
If the reason looks like a billing or paperwork problem, call the doctor's billing office and ask them to check the claim and resubmit it. Then call the carrier. The number is on your ID card. Ask:
- Why exactly was this claim denied?
- Can it be reprocessed if the provider corrects and resubmits it?
- If not, how do I appeal, and what is the deadline?
- What should I send with the appeal?
Note the date, the name of the person you spoke to and any reference number for each call.
Step 5: Appeal in writing if you need to
An appeal is a request for the carrier to look at the claim again. The denial notice or your plan documents explain how to file it and by when, so follow those steps and keep a copy of everything you send. A letter from your doctor explaining why the care was needed, and the records behind it, can help your case.
Picture it
A denial arrives for a scan you had last month. The reason is a code you do not understand. You pay the bill because you do not know what else to do, and you never find out that the problem was a single wrong code on the claim form.
Now picture the other version. You call us with the EOB in hand. We read it with you, the reason points to the billing, and you know exactly what to ask the doctor's office. If the claim still comes back denied, you know how the appeal works, what to send and the date it is due, before you pay anything.
Heading off the next denial
- Ask whether a service needs pre-authorization before you book it.
- Check that a new doctor is in your network before the first visit.
- Know the date your coverage starts, and keep the old plan until then.
- Know whether your plan is major medical or limited medical, and where any caps sit.
More questions about claims and service are answered in our FAQ.
This is general education, not legal advice and not a guarantee that a claim will be paid. The carrier issues the policy and pays the claims, and appeal steps and deadlines depend on the plan, the carrier and your state.