What to do if your insurance claim or pre-authorization is denied in New York

The killing of UnitedHealthcare CEO Brian Thompson has created a conversation about the health insurance industry. One consistent problem we’ve been hearing from community members is how often their claims or pre-authorizations are denied, even when their doctors say the procedures are necessary.

Data from the health research organization KFF found that people whose plans are from the Healthcare.gov marketplace saw denial rates of 17% on average. However, depending on the plan, customers were denied between 2% and 49% of claims. And while denial data from private insurance companies are typically not publicly available, KFF found that those with private insurance are twice as likely to have their coverage denied when compared to those with public coverage.

But a denial doesn’t mean you have no choice but to pay or skip treatment. It’s possible to have the decision reversed.

We spoke with Diane K. Spicer, supervising attorney at the nonprofit Community Health Advocates, on what to do if you receive an insurance claim or pre-authorization denial. One caveat: Spicer says a step-by-step guide isn’t necessarily a simple thing when it comes to insurance, because different insurances can have different rules.

As a reminder, while pre-authorizations and claims are different things, the process of fighting their denials is similar.

Step 1: Understand the denial

Carefully review the letter. Denials can happen for several reasons, including:

the insurer claims the service isn’t medically necessary
billing and coding errors
out-of-network restrictions
administrative denials, like uncovered benefits or disputes over how much the insurer pays

If the notice is unclear, call your insurance company, provider, or an advocate to clarify what the denial means.

Step 2: Review your insurance policy

Take a close look at your member handbook. Yes, it can be a lot of information and often confusing. But it also includes:

what services are covered under your plan
whether you have out-of-network benefits
timeframes for filing appeals (often 180 days for internal appeals, but it varies by plan)
how claims should be submitted

Understanding your policy is key to learning whether the denial was appropriate and how you can proceed.

Step 3: Gather your proof

Once you understand why your claim was denied, collect all relevant documents:

For medical necessity denials:
- request the specific criteria the insurer used to deny your claim
- ask for any notes or files from the insurer related to their decision
- request your medical records from your doctor or provider.
- ask your doctor for a letter of support explaining why the treatment is necessary
  - the letter should highlight how your medical records meet the insurer’s criteria and address any missing or incorrect information in your records (for instance, a history of when you stopped smoking, if required)

For administrative denials:
- depending on the type of administrative denial, gather corrected billing codes or proof of network status.

Step 4: File an internal appeal

Submit an appeal directly to your insurance company. Here’s how:

write a detailed appeal letter explaining why the denial should be overturned.
include all supporting documents, such as medical records and letters from your doctor.
submit the appeal within the required timeframe (usually 180 days but varies by plan).
keep copies of everything you send.

For Medicaid-managed care plans, note that pre-authorization denials (also known as initial adverse determinations) must be appealed within 60 days.

Step 5: Request an external review (if applicable)

If your internal appeal is denied and it involves medical necessity, you have the right to request an external review in New York. This process allows an independent medical expert to review your case.

What to know:

the external reviewer must use nationally recognized standards of care.
you can request this review through the New York Department of Financial Services.

But note that administrative denials (e.g., billing issues) are not eligible for external review. In these cases, filing a complaint with state regulators may be an option.

Other best practices include ensuring that you:

Know your rights

In New York, insurers are required by law to:

provide detailed reasons for denials and the criteria used
share all relevant files and notes upon request
offer a legally mandated appeals process with clear timelines.

Patients also have the right to access their medical records and use them in their appeals.

Follow timeframes

Appeals must often be filed within strict deadlines. It’s best to get ahead of the timeline.

Exercise persistence

Many denials are overturned during the appeals process, especially when errors or missing information are addressed.

Seek help from advocates

If you’re unsure how to proceed or feel overwhelmed, reach out to organizations that provide free support with navigating denials and filing appeals. Some of these include: