Questions & answers · Health insurance
My coverage is an insurance policy, and the Explanation of Benefits says denied with zero paid. What must that notice include?
Health insuranceDeniedChecked Nov 6, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: govinfo · 45 CFR 147.136 (2024) · § 147.136(b)(2)(ii)(E) «Notice» View original ↗
In short
What this means
Your coverage runs on a federal notice rule for health insurance. The plan and the issuer must give you notice in a culturally and linguistically appropriate manner [1]. That notice has to comply with the group plan notice rules at 29 CFR 2560.503-1(g) and (j) [1]. And it has to meet a list of extra requirements on top of those [1]. The items below are that list.
First, the notice must let you identify the claim. It must include the date of service, the health care provider, and the claim amount, if a claim amount applies [2]. It must also carry a statement that the diagnosis code and its meaning, and the treatment code and its meaning, are available on request [2]. Then you can ask. The issuer must give you those codes and their meanings as soon as practicable upon request [3]. And here is the part people get wrong. A request for that code information is not, by itself, a request for an internal appeal or an external review [3]. So asking does not spend your appeal.
Second, the reason itself has to be readable. The reason or reasons for the denial must include the denial code and its corresponding meaning [4]. It must also include a description of the plan or issuer standard, if any, that was used in denying the claim [4]. If this is the final internal denial, that description must include a discussion of the decision [4].
Third, the notice must point you to the next door. It must describe the internal appeals and external review processes available, including how to start an appeal [5]. And it must disclose the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman that assists people with these processes [5]. So if your notice is missing the code meaning, or the standard used, or the appeal instructions, say so in writing when you appeal. These are the rules for health insurance coverage. Does your employer pay its own claims instead? Then ask the plan administrator which rule it is applying.
Your next step
Write to the insurer and ask for four things in one letter. Ask for the denial code and its meaning [4]. Ask for the standard that was used to deny the claim [4]. Ask for the diagnosis code and the treatment code, with their meanings [3]. And ask for the description of the internal appeal and external review processes [5]. Say in the letter that the code request is not your appeal [3]. These sources give no deadline for that request. The deadline to watch is your plan's appeal window, which the notice itself must state [1] [5].
Check it yourself
Open the notice and find the date of service, the provider, and the claim amount [2]. Then look for the sentence saying the diagnosis and treatment codes are available on request [2]. Then look for the denial code with its meaning, and for the standard that was used [4]. Then find the appeal instructions and the consumer assistance contact [5]. What your own denial code stands for: "Don't know yet" here until the insurer writes it out.
Where this comes from (5)
[1] govinfo · 45 CFR 147.136 (2024) · § 147.136(b)(2)(ii)(E) «Notice» · checked 2026-11-06
Notice. A plan and issuer must provide notice to individuals, in a culturally and linguistically appropriate manner (as described in paragraph (e) of this section) that complies with the requirements of 29 CFR 2560.503-1(g) and (j). The plan and issuer must also comply with the additional requirements of this paragraph (b)(2)(ii)(E).
[2] govinfo · 45 CFR 147.136 (2024) · § 147.136(b)(2)(ii)(E)(1) «Notice» · checked 2026-11-06
The plan and issuer must ensure that any notice of adverse benefit determination or final internal adverse benefit determination includes information sufficient to identify the claim involved (including the date of service, the health care provider, the claim amount (if applicable), and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code a…
[3] govinfo · 45 CFR 147.136 (2024) · § 147.136(b)(2)(ii)(E)(2) «Notice» · checked 2026-11-06
The plan and issuer must provide to participants, beneficiaries and enrollees, as soon as practicable, upon request, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning, associated with any adverse benefit determination or final internal adverse benefit determination. The plan or issuer must not consider a request for such diagnosis and treatment information, in itse…
[4] govinfo · 45 CFR 147.136 (2024) · § 147.136(b)(2)(ii)(E)(3) «Notice» · checked 2026-11-06
The plan and issuer must ensure that the reason or reasons for the adverse benefit determination or final internal adverse benefit determination includes the denial code and its corresponding meaning, as well as a description of the plan's or issuer's standard, if any, that was used in denying the claim. In the case of a notice of final internal adverse benefit determination, this description must include a discussio…
[5] govinfo · 45 CFR 147.136 (2024) · § 147.136(b)(2)(ii)(E)(4)-(5) «Notice» · checked 2026-11-06
The plan and issuer must provide a description of available internal appeals and external review processes, including information regarding how to initiate an appeal. ( 5 ) The plan and issuer must disclose the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman established under PHS Act section 2793 to assist individuals with the internal claims an…
How we found this
We matched your question to 5 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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