Get the facts: Why was my claim denied, and what can I do about it?

• Claims denials are not nearly as common as you might think based on what you see on social media.
• After completing its review process, UnitedHealthcare’s claims approval rate stands at 98% for claims for eligible members, when submitted in a timely manner with complete information, and after duplicate claims are removed.
• If a claim for care you received isn’t approved, you have the right to file an appeal, and in some cases, to request an external review of your claim by an independent third party, who will review the claim and issue a final decision.
• The best thing you can do to minimize the chances that your claim won’t be approved is to be proactive about understanding your coverage before you receive care.

When you think about what’s important in healthcare, being able to get the care you need at a price you can afford is probably at the top of the priority list. So when the health system doesn’t meet your expectations in either of these areas — access or affordability — it’s understandably frustrating.

There is a lot of conversation about insurance companies and “denial rates,” but in reality, the vast majority of Americans’ experience with healthcare coverage is simple and straightforward. If you do end up receiving a denial for a claim, read on to learn more about why you received it and what you should do next.

It’s not nearly as common as you might think based on what you see on social media. In fact, the majority of people who responded to a Kaiser Family Foundation survey in January 2026 said they had not experienced a denied claim in the last two years.¹

That’s because getting care and coverage works as expected most of the time. You get a check-up or treatment, and your provider receives payment from your health insurer. That’s it. That exact scenario plays out millions of times every single day.

At UnitedHealthcare, we approve and pay 90% of claims shortly after they’re submitted. The remaining 10% go through an additional review process. After that review process is completed, UnitedHealthcare’s claims approval rate stands at 98% for claims for eligible members, when submitted in a timely manner with complete information, and after duplicate claims are removed.²

When a claim isn’t approved right away, it’s usually due to missing information or questions that need to be resolved — not a final decision about what will be covered.

Claims that go through further review after their initial submission typically fall into one of these categories:

• Eligibility: There’s a possibility the patient is not actually enrolled in the health plan.
• Duplicates: The provider inadvertently submitted multiple claims for the same treatment or service.
• Documentation: The provider didn’t submit all the information necessary to review the claim, such as the results of lab tests or diagnostic imaging tools like MRIs and CT scans.
• Coverage: The plan sponsor — the employer, the federal government through Medicare, a state government through Medicaid or the private health insurance company that offers the Medicare Advantage or Affordable Care Act marketplace plan you choose — opted not to include coverage for that particular service or procedure when designing their health plan.
• Clinical quality and safety: The care provided does not align with widely accepted, evidence-based clinical guidelines. In some cases, providers recommend services that may not be supported by the current clinical evidence and established standards. 

First of all, don’t panic. It’s important to know that the letter is likely not the end of the story. It could signal that your claim is still moving through the insurer’s review process, and once that process is completed, it could end up being approved and paid. Check out this article for more on why insurers send letters and what you should do if you receive one. 

Even if your insurer ultimately does not approve your claim, you have the right to file an appeal. Many denials are resolved through additional review or appeal, especially when more information is provided.

If your claim isn’t approved, you have the right to appeal. The letter from your health plan will include an explanation of the steps you should take if you’d like to file an appeal.

• Typically, you’re required to file this request in writing.
• It’s important to know that you usually have a limited period of time when you’re eligible to file an appeal. For most plans, that’s 180 days from the date your insurer sent the first notification.
   

If you need help or have questions about the appeals process, resources are available:

• The member services representatives at your health plan can answer your questions and support you through the appeals process. You can reach them by calling the number on the back of your health plan ID card.
• Health plans also provide information about how to file an appeal on their member websites and mobile apps.
• If you are enrolled in an employer-sponsored plan and your employer is self-insured, meaning it covers the costs of its employees’ care, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272).
• If you are enrolled in a fully insured employer-sponsored plan, the Department of Health and Human Services Health Insurance Assistance Team can assist you. The number is 1-888-393-2789.
• If you’re not sure if your employer’s plan is self-insured or fully insured, contact your human resources department.
• If you are enrolled in Medicare, this appeals guide provides step-by-step instructions. You can also call 1-800-MEDICARE 24 hours a day, seven days a week, or reach out to your State Health Insurance Assistance Program for free, personalized counseling to help you navigate the appeals process.
• If you are enrolled in Medicaid, contact your state’s department of Medicaid. Your state or city might also have legal aid societies that can offer free advice to help you file an appeal.

In some cases, you can request an external review of your claim by an independent third party, who will review the claim and issue a final decision. Claims are eligible for external review if they weren’t approved for clinical reasons, such as if your health plan considered the care experimental. When claims aren’t approved for administrative reasons, such as the sponsor of your health plan choosing not to cover that particular service or procedure, they’re typically not eligible for external review.

If your provider ultimately sends you a bill, payment plans or other patient assistance programs may be available. Give your provider a call to see what type of support may be available to you.

The best thing you can do is to be proactive about understanding your coverage before you receive care. It’s always a good idea to check your plan benefits before receiving care to ensure the care is covered by your plan and that the care provider you’re planning to see is included in your plan’s network.

• To check your benefits and provider network, you can log into your health insurer’s member portal or mobile app.
• You can also call the number on your health plan ID card to speak with a member services representative. Some insurers also offer member support via chat services available on their websites or apps.
• If your plan doesn’t cover the service you need, talk with your doctor about alternative treatment options.
• If you’re enrolled in a self-insured employer-sponsored plan, you can reach out to your human resources department to ask if they’d be willing to make an exception so the care your doctor is recommending will be covered by your plan. Because self-insured employers have far more control over the design of their health plans and the care that’s covered, they’re in a position to make exceptions to the coverage terms in certain cases.
   

Taking a few minutes to check your benefits or confirm your provider is in-network can help prevent surprises later — and give you more confidence in your care decisions.

Chances are, you’ll never need to use the information in this article since the vast majority of healthcare claims are approved and paid without issue. But if something doesn’t go as expected, it’s important to know you have options — and that support is available. Whether it’s understanding the status of a claim, filing an appeal or requesting a review from an independent third party, your health plan can help you through this process so you can focus on what matters most: your health.  

Read more Get the Facts articles.