👎 How to Dispute a Healthcare Reimbursement Denial: 5 Proven Steps for Providers
Getting a reimbursement denial from an insurance payor is more than just frustrating—it can threaten your revenue, disrupt your cash flow, and create endless administrative headaches.
Whether it’s a timely filing denial, an unexpected recoupment request, or a cryptic denial code, many healthcare providers feel powerless. But here's the truth: you have the right to appeal, and you can often win—if you know what to do.
This step-by-step guide will show you how to dispute healthcare claim denials effectively and protect your bottom line.
✅ Step 1: Understand Why the Claim Was Denied
Start with the basics—what exactly did the payor say?
Carefully review the:
Explanation of Benefits (EOB)
Remittance Advice (RA)
Denial letter from the insurer
Look for:
Denial reason codes (e.g., CO-29 = “timely filing”)
Deadlines for submitting an appeal
Any mention of payor policy manuals or contract terms
Understanding the denial code gives you the leverage to respond strategically—not emotionally.
📂 Step 2: Gather Strong Supporting Documentation
Before you appeal, collect the documents that prove your case. These may include:
Proof of timely filing (EHR timestamps, clearinghouse receipts, certified mail logs)
Patient encounter notes and clinical documentation
Billing submission history
Contract terms and payor guidelines
The stronger your paper trail, the harder it is for the payor to defend an unjustified denial.
✍️ Step 3: Draft a Targeted and Professional Appeal Letter
Keep it short, factual, and focused. A strong appeal letter should:
Reference the denial reason
Explain why it’s incorrect or doesn’t apply
Attach supporting documents
Request specific corrective action (e.g., claim reprocessing, recoupment reversal)
Be sure to include:
Provider NPI and TIN
Patient ID and date(s) of service
Audit reference number, if applicable
📬 Step 4: Submit the Appeal the Right Way
Send your appeal through the designated method outlined by the payor:
Provider portal (preferred by most major payors)
Certified mail with return receipt
Fax (still accepted by many plans)
Secure email (if permitted)
Always save confirmation receipts, screen captures, and tracking numbers. Follow up with a representative to verify receipt and next steps.
⏳ Step 5: Follow Up—and Escalate if Needed
Payors are usually required to respond to appeals within 30–60 days. If they don’t, or if the appeal is denied:
Request a second-level appeal if available
File a formal provider complaint with your state Department of Insurance or Medicaid agency
Consider hiring a healthcare attorney to assist with large-dollar or repeated denials
Don’t let silence or rejection be the end of the story—persistent follow-up is often the key to getting paid.
🧠 Final Thoughts
Reimbursement denials don’t have to be the final word. With a strategic approach, proper documentation, and professional persistence, small and midsized healthcare providers can successfully appeal denials and recoup lost revenue.
Need help untangling a denial, drafting an appeal, or challenging a recoupment? Let’s talk.
Hurley Law Group
Healthcare Law for Small & Midsized Providers
📞 308-383-1867
🌐 hurleylawgroup.com
✉️ eric@hurleylawgroup.com