Denial Letter Decoder

What each part of a health insurance denial letter means, and what to do with it. Letters vary, but most follow this order. This page follows the order of the federal model notice for denials. (CMS model notice, via HealthCare.gov)

1. Case details. The claim number, date of service, provider, amount, and often a denial code. Write the claim number at the top of every page and use it on every call.

2. Reason for denial. The one sentence that says why they said no. Highlight it. Your appeal has to answer this sentence.

3. Basis for the decision. The plan rule, policy or medical guideline they used. Ask for a copy of that rule. They have to send it free if you ask.

4. How to file an appeal. Where to send it and how: a form, mail, fax or portal. Find your deadline. Most private plans allow 180 days from the day you get the notice.

5. If it's urgent. How to ask for a fast (expedited) appeal. If waiting could seriously harm your health, ask. These are generally decided within 72 hours.

6. Copies of your information. Your right to free copies of the documents used for the decision, plus the billing and diagnosis codes. Request your claim file. A coding error can be the whole problem.

7. What happens next. External review, by an independent reviewer outside the company. If the internal appeal is denied, you can usually ask for this.

8. Free help. Your state's department of insurance, and its Consumer Assistance Program if it has one. Call them if you get stuck. See our full Who will help me for free? page.

Circle three dates

The date on the notice (to be safe, count your deadline from here), your appeal deadline (put it on your calendar a week early), and the day you send your appeal (keep proof, like a fax receipt, tracking number or screenshot).

Make one call first

Ask: "What is the exact reason and denial code?" "What is my appeal deadline?" "What information would change this decision?" "Can I have a reference number for this call?"

A sample, marked up

A made-up sample denial letter with its 8 parts numbered: case details, reason for denial, basis for the decision, how to file an appeal, if it's urgent, copies of your information, what happens next, and free help. Stamped "Sample. Not a real letter."

This sample is made up. The names and numbers are fake.

Want a printable copy? Get the one-page PDF free here: https://payhip.com/b/OGYwp

Medicare and Medicaid have their own appeal steps, so go by your own notice.

This is general educational information, not legal or medical advice. Rules and deadlines vary by plan and state, so always follow the instructions on your own letters and notices. The Denial Desk is not affiliated with any insurer, hospital, or government agency.

AI disclosure: This page was drafted with help from AI tools, then reviewed and fact-checked by our founder, a certified medical coding professional.

Last reviewed: October 2026

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