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My Explanation of Benefits says the claim was denied and the plan paid zero. What must the plan tell me, and can I appeal?

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 (2025) · § 2560.503-1(m)(4)(i) «Definitions» View original ↗

In short

  1. A zero payment counts as a denial you can appeal [1].
  2. Ask the plan in writing for the reason and the rule it used [2] [3].
  3. You get at least 180 days from the notice to appeal [4].

What this means

Start with what the law calls this. An adverse benefit determination means a denial, a reduction, or a termination of a benefit [1]. It also means a failure to provide or make payment, in whole or in part [1]. So a line that pays zero is one of these. That matters, because the notice rules and the appeal clock both hang on it.

The notice has to say certain things, in a manner calculated to be understood by you [2]. It must give the specific reason or reasons for the decision [2]. It must point to the specific plan provisions the decision is based on [2]. If something is missing from your claim, the notice must describe what is needed and explain why [2]. And it must describe the plan review procedures and the time limits that apply, with a statement of your right to bring a civil action under section 502(a) of the Act [2].

Two more items are worth asking for by name. Did the plan rely on an internal rule, guideline or protocol? Then the notice must give you that rule, or say that such a rule was relied on and that a copy will be provided free of charge on request [3]. Was the denial based on medical necessity, or on an experimental treatment or similar exclusion? Then it must explain the scientific or clinical judgment for the decision, applying the plan terms to your medical circumstances. Or it must say that the explanation will be provided free of charge on request [3].

Then the clock, and what comes after. The plan must give you at least 180 days after you receive the notice to appeal [4]. If the appeal goes against you, that second notice has its own list. It must give the specific reasons and the plan provisions it rests on [5]. And it must state that you may receive, free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim [5]. These are the rules for a plan your employer runs itself. Is your coverage an insurance policy instead? Then ask the insurer which rule it is applying to your claim.

Your next step

Write to the plan and ask for three things in one letter. Ask for the specific reason and the plan provision the denial rests on [2]. Ask for the internal rule or guideline that was relied on, free of charge [3]. And ask for the scientific or clinical judgment, if the denial was about medical necessity [3]. Then date your appeal from the day you received the notice: you have at least 180 days [4]. Ask the plan to confirm, in writing, the date it received your appeal. Keep a copy of every letter, with the date you sent it.

Check it yourself

Find the notice that came with the zero payment, and look for the specific reason and the plan provision [2]. Then look for the sentence about a rule or guideline, and the one about your right to sue under section 502(a) [2][3]. Then count 180 days from the date you received it [4]. What the plan denial code on your form stands for: "Don't know yet" here, so ask the plan to write out the code and its meaning.

Where this comes from (5)

  1. [1] govinfo · 29 CFR 2560.503-1 (2025) · § 2560.503-1(m)(4)(i) «Definitions» · checked 2026-11-06

    The term "adverse benefit determination" means: (i) Any of the following: A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan

  2. [2] govinfo · 29 CFR 2560.503-1 (2025) · § 2560.503-1(g)(1)(i)-(iv) «Manner and content of notification of benefit determination» · checked 2026-11-06

    The notification shall set forth, in a manner calculated to be understood by the claimant— (i) The specific reason or reasons for the adverse determination; (ii) Reference to the specific plan provisions on which the determination is based; (iii) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; …

  3. [3] govinfo · 29 CFR 2560.503-1 (2025) · § 2560.503-1(g)(1)(v)(A)-(B) «Manner and content of notification of benefit determination» · checked 2026-11-06

    In the case of an adverse benefit determination by a group health plan— (A) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a cop…

  4. [4] govinfo · 29 CFR 2560.503-1 (2025) · § 2560.503-1(h)(3)(i) «Appeal of adverse benefit determinations» · 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;

  5. [5] govinfo · 29 CFR 2560.503-1 (2025) · § 2560.503-1(j)(1)-(3) «Manner and content of notification of benefit determination on review» · checked 2026-11-06

    In the case of an adverse benefit determination, the notification shall set forth, in a manner calculated to be understood by the claimant— (1) The specific reason or reasons for the adverse determination; (2) Reference to the specific plan provisions on which the benefit determination is based; (3) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies…

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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