Insurance denial reasons explained

Most common denial reasons

Not medically necessary

The insurer determined the service didn't meet their criteria. One of the most common denials — and most frequently overturned on appeal with physician documentation.

Prior authorization required

The service required advance approval that wasn't obtained. A retrospective review may be possible if the service was already received.

Service not covered

The service is excluded from your plan. Verify against your Summary of Benefits — coverage exclusions are sometimes misapplied.

Out-of-network provider

Provider not in your network. No Surprises Act or out-of-network benefits may apply depending on circumstances.

Timely filing exceeded

Claim submitted after the insurer's deadline. Difficult to overturn but may be appealed if there was a valid reason for the delay.

Missing or invalid information

Claim was missing required information. Usually resolved by resubmitting with correct information.

General information only. Not legal or medical advice.