Questions & answers · Health insurance

Health insurance claim questions

225 short answers. Each one quotes the official rule it is based on, with the date we checked it. Information only — not legal advice.

Any state · federal rules (94)

• Medicare refused a service. Will my Medigap policy pay it instead?Denied
• My care is urgent. Can my health plan appeal be faster?Appeal
• My child's CHIP plan denied a service. Can I get an independent review?Complaint / outside review
• My claim was denied because I have other insurance. Who pays first?Denied
• My claim was denied because of a billing or coding problem. What now?Denied
• My coverage is an insurance policy, and the Explanation of Benefits says denied with zero paid. What must that notice include?Denied
• My doctor asked my health plan for prior approval. How long does the plan have to answer?How to file
• My doctor didn't file my Medicare claim and I paid out of pocket. Can I file it myself?How to file
• My doctor hasn't filed my Medicare claim, or I got a bill. How do I check, and is there a time limit?Slow or stuck
• My doctor just left my plan's network in the middle of my treatment. Can I keep seeing them at in-network cost?Who pays
• My employer health plan denied my claim. Why, and is that allowed?Denied
• My employer health plan denied prior authorization. How long do I have to appeal, and how fast must they decide?Appeal
• My employer health plan has not decided my claim. What can I do?Slow or stuck
• My employer health plan won't give me the plan documents or my claim file. What are my rights?Appeal
• My employer offers health insurance. Can I still get a Marketplace premium tax credit in 2026?Buying a policy
• My Explanation of Benefits says the claim was denied and the plan paid zero. What must the plan tell me, and can I appeal?Denied
• My health insurance claim is delayed. What can I do?Slow or stuck
• My health insurance denied my claim for an illness or injury. Why, and is that allowed?Denied
• My health insurance denied my claim. Which appeal rules apply to me?Other
• My health insurance paid less than I expected. Is there a way to challenge it?Paid too little
• My health insurer (for example UnitedHealthcare) denied my in-network hospital claim. How do I appeal?Appeal
• My health plan denied a vaccine shot. Don't health plans have to cover vaccines?Denied
• My health plan denied prior approval for care. How do I appeal, and how fast?Appeal
• My health plan denied therapy. Do Marketplace plans have to cover mental health care?Denied
• My health plan dropped my medication from its formulary. How do I get an exception?Appeal
• My health plan dropped my medication from the formulary. How do I get an exception?Appeal
• My health plan says I don't have coverage for something, but my summary of benefits says I do. What can I do?Denied
• My health plan says the care wasn't medically necessary. What do I do, step by step, and by when?Denied
• My health plan upheld its denial after my internal appeal. What is external review?Complaint / outside review
• My health plan won't cover my birth control. Do they have to?Denied
• My HealthCare.gov plan denied a claim 5 months ago. Is it too late to appeal?Deadlines
• My insurer cancelled my coverage back to the start date and wants the claims back. Can they do that?Denied
• My insurer denied my ER visit because it says it wasn't an emergency. Is that allowed?Denied
• My insurer wants to stop paying for ongoing physical therapy. Do they have to keep paying while I appeal?Appeal
• My job's plan pays its own claims. The clinic filed late, the plan denied it, and now the office wants the money from me. What are my rights?Who pays
• My marketplace (ACA) plan denied a claim. How do I file an internal appeal?Appeal
• My Marketplace health plan dropped me for not paying my premium. What are my rights?After payment
• My marketplace plan denied an out-of-network specialist visit. Can I appeal?Appeal
• My Medicaid application was denied. How long should a decision take, and how do I appeal?Denied
• My Medicaid health plan denied a service. What are the steps and deadlines?Appeal
• My Medicaid health plan hasn't decided my prior authorization request. How long can it take?Denied
• My Medicaid plan denied a service. How do I appeal and by when?Appeal
• My Medicare Advantage plan denied a service. How does the appeal work?Appeal
• My Medicare Advantage plan denied a service. How long do I have to appeal?Appeal
• My Medicare Advantage plan denied a skilled nursing facility stay that traditional Medicare would have covered. Is that allowed?Denied
• My Medicare Advantage plan denied my hospital stay as not medically necessary. How do I appeal and how fast must they decide?Appeal
• My Medicare claim seems stuck. How do I check it, and is there a deadline?Slow or stuck
• My Medicare drug plan won't cover my prescription. How do I appeal?Appeal
• My Medicare Part D plan won't cover my drug. How do I ask for an exception and how fast must they decide?Appeal
• My Medicare premium went up because of my income (IRMAA), but my income dropped. How do I get it lowered?Appeal
• My Medicare Summary Notice shows a service as denied. Do I owe money, and what do I do?Denied
• My plan denied it because I didn't get prior approval. What can I do?Denied
• My plan denied the claim because the provider was out of network. Is that allowed?Denied
• My plan denied the claim saying it's a pre-existing condition. Is that allowed?Denied
• My plan says my claim is excluded or not a covered benefit. What can I check?Denied
• My plan says my treatment is experimental. Can I fight that?Denied
• My plan says preventive care is free, so why did I get a bill for my checkup?Denied
• My plan won't cover my prescription without prior approval, or says the drug isn't on its list. What can I ask for?Denied
• My provider asked me to sign an ABN. What does it mean, and which option should I pick?Who pays
• My provider didn't file my Medicare claim. How do I file it myself, and by when?How to file
• Original Medicare denied my claim. How long do I have to appeal, and how fast must they answer?Appeal
• Original Medicare denied my claim. What are the appeal levels and deadlines?Appeal
• Original Medicare denied my claim. What are the appeal steps and deadlines?Appeal
• The hospital changed me from inpatient to "observation." What does that mean for my bill, and can I appeal?Appeal
• What do I pay for a hospital stay in Original Medicare in 2026?Who pays
• What does a Medicare Advantage denial notice have to tell me?Appeal
• What does a Medigap plan pay, and what is the difference between Plan G and Plan C?Buying a policy
• What does Medicare Part B cost in 2026: premium, deductible and the 20%?Who pays
• What happens after my Medicare Advantage plan keeps its denial on appeal?Appeal
• What is an out-of-pocket maximum and what does it not include?Who pays
• What is external review of a health insurance denial, and how long does it take?Appeal
• What is Extra Help for Medicare drug costs and who qualifies?Buying a policy
• What is Medigap, when can I buy it, and what does it cost?Buying a policy
• What is the difference between Bronze, Silver, Gold and Platinum health plans?Buying a policy
• What is the difference between Original Medicare and a Medicare Advantage plan?Buying a policy
• What is the Medicare Part B late enrollment penalty?Buying a policy
• What is the Part D late enrollment penalty and how is it figured?Buying a policy
• What percentage of health insurance claims are denied in the US?Denied
• What will I pay for Medicare Part D drugs in a year?Buying a policy
• What's the difference between bronze, silver, gold and platinum health plans?Buying a policy
• What's the difference between Bronze, Silver, Gold and Platinum Marketplace plans?Buying a policy
• When can I sign up for Medicare and when does my coverage start?Buying a policy
• When can I switch from traditional Medicare to a Medicare Advantage plan, or go back?Buying a policy
• When does my Medicare coverage start, and what if I sign up late?Buying a policy
• When should I buy a Medigap policy and how do I choose one?Buying a policy
• Which appeal rules apply to my health coverage?Appeal
• Which outpatient prescription drugs does Medicare Part B cover?Who pays
• Why is my Medicare Part B premium higher than $202.90? Does my income change it?How to file
• Will Medicaid keep paying for my care while my appeal is pending?Appeal
• Will Medicaid keep paying for my care while my appeal is pending?Appeal
• Will Medicare pay for a nurse or aide at home?Who pays
• Will Medicare pay for a nursing facility stay after the hospital?Who pays
• Will Medicare pay for a stretcher (ambulance) ride home from the hospital?Who pays
• Will Medicare pay for my ambulance ride?Who pays

California (4)

• My California health insurer says it never got my claim, and I paid cash. How do I file the claim myself?How to file · California
• My doctor is leaving my California HMO's network in the middle of my treatment. Can I keep seeing them at the in-network rate?Who pays · California
• My EOB says the claim was denied, but I owe $0 for an out-of-network bill at my in-network California hospital. What's going on?Denied · California
• My provider filed my claim late in California — can they bill me for the denied amount?Who pays · California

New York (1)

• How do I ask New York State for an external appeal after my health insurer denied my claim?Complaint / outside review · New York

Texas (1)

• After my Texas health insurance claim for an illness or injury, what about repayment, subrogation or premium changes?After payment · Texas