My claim was denied because of a billing or coding problem. What now?

Health insuranceDeniedChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: GovInfo · 29 CFR § 2560.503-1 «Claims procedure: notice of an adverse benefit determination» · paragraph (g)(1) View original ↗

In short

Some denials are about how the claim was billed, not the care.
Get your claim file for free and compare it with the provider's bill.
Call the billing office with the exact reason, then appeal if needed.

What this means

The federal rule says a denial notice must give the specific reasons and refer to the plan provisions the decision is based on [1].

You can also get your claim documents free on request [2]. An employer group plan must give you at least 180 days after you receive the notice to appeal [3]. The external review process must allow at least four months after the notice to ask for it [5].

Your next step

Ask the plan for your claim file free of charge [2] and read the specific reason in the notice [1]. Send your appeal within the time on the notice; an employer group plan must give you at least 180 days after you receive it [3]. For outside review, the process must allow at least four months after the final denial [5].

Check it yourself

Open HealthCare.gov, «External review», at https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ and read the part quoted above. Your plan's own notice and rules apply to you: "Don't know yet" for your case.

Where this comes from (6)

[1] GovInfo · 29 CFR § 2560.503-1 «Claims procedure: notice of an adverse benefit determination» · paragraph (g)(1) · checked 2026-11-06
The specific reason or reasons for the adverse determination; ( ii ) Reference to the specific plan provisions on which the determination is based
[2] GovInfo · 29 CFR § 2560.503-1 «Claims procedure: appeal rights» · paragraph (h)(2)(iii) · checked 2026-11-06
Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits
[3] GovInfo · 29 CFR § 2560.503-1 «Claims procedure: appeal time» · paragraph (h)(3)(i) · checked 2026-11-06
Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination
[4] GovInfo · 29 CFR § 2560.503-1 «Time for the decision on review» · paragraph (i)(2)(i)–(iii) · checked 2026-11-06
In the case of a claim involving urgent care, the plan administrator shall notify the claimant, in accordance with paragraph (j) of this section, of the plan's benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claimant's request for review of an adverse benefit determination by the plan … In the case of a pre-service claim…
[5] GovInfo · 45 CFR § 147.136 «External review: time frames» · external review process · checked 2026-11-06
at least four months after the receipt of a notice of an adverse benefit determination or final internal adverse benefit determination for a request for an external review to be filed … within no more than 45 days after the receipt of the request for external review by the IRO … As expeditiously as possible but within no more than 72 hours after the receipt of the request for expedited external review by the IRO
[6] HealthCare.gov · checked 2026-11-06
If your health insurance company is using the HHS-Administered Federal External Review Process, there's no charge. If your issuer has contracted with an independent review organization, or is using a state external review process, you may be charged. If so, the charge can't be more than $25 per external review … Call toll free: 1-888-866-6205 to request an external review request form

How we found this

We matched your question to 6 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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