Health Insurance Claim Denial: the call script
Insurers deny first and hope you give up. A large share of appeals succeed — but only if you appeal. This playbook walks you through the call and the paper trail.
Know your rights (plain English)
- Right to appeal — Under the Affordable Care Act, you can appeal when your insurer denies a claim — first an internal appeal with the insurer, then an external review by an independent third party if needed. (Affordable Care Act)
- Denial in writing — You are entitled to a written explanation of why the claim was denied, including the specific reason and how to appeal. (ACA)
- No surprise emergency bills — Federal law protects you from surprise out-of-network bills for emergency services — you generally owe only your normal in-network cost share. (No Surprises Act (2022))
- State insurance commissioner — Every state has an insurance department that takes consumer complaints — insurers respond to these. (State law)
The call script
Opening line
"Hi, I'm calling to appeal the denial of claim [CLAIM NUMBER] for [SERVICE] on [DATE]. I'd like to understand the exact reason for the denial and start a formal appeal."
"Hi, I'm calling to appeal the denial of claim [CLAIM NUMBER] for [SERVICE] on [DATE]. I'd like to understand the exact reason for the denial and start a formal appeal."
1. Get the reason on record
"Ask: 'Can you read me the exact denial reason and the policy clause it's based on? And please send that to me in writing.'"
"Ask: 'Can you read me the exact denial reason and the policy clause it's based on? And please send that to me in writing.'"
2. Start the internal appeal
"Say: 'I'd like to formally initiate an internal appeal today. What's the deadline, and where do I send supporting documents from my doctor?'"
"Say: 'I'd like to formally initiate an internal appeal today. What's the deadline, and where do I send supporting documents from my doctor?'"
3. Ask about external review
"Ask: 'If the internal appeal is denied, how do I request an external review?'"
"Ask: 'If the internal appeal is denied, how do I request an external review?'"
When they push back
They say: "The service isn't covered by your plan."
You say: "Please send me the exact policy language. My doctor documented this as medically necessary — I'd like that reviewed by your medical review team, not just the claims desk."
They say: "The appeal will take 60 days."
You say: "I understand — please confirm the appeal is filed today and give me a reference number. Is there an expedited review option given [my situation]?"
They say: "There's nothing more I can do."
You say: "Please escalate this to a supervisor. Also note on the account that I'm requesting written denial details and appeal instructions."
They say: "You need prior authorization — it's too late now."
You say: "I'd like to file a retroactive authorization request with my doctor's office. Please tell me exactly what documentation you need."
Before you call — documentation checklist
- Claim number and denial letter
- Your policy's appeals section (screenshot it)
- Doctor's notes showing medical necessity
- Dates of service and provider details
- Reference numbers for every call
- Your state insurance department's complaint page bookmarked
After the call — follow-up email
Copy, fill in the brackets, send. This creates the paper trail.
Subject: Formal appeal of denied claim [NUMBER]
Hello,
I'm formally appealing the denial of claim [NUMBER] for [SERVICE] provided on [DATE] by [PROVIDER], in the amount of $[AMOUNT].
The denial reason given was: "[REASON]". My treating physician, Dr. [NAME], has documented this service as medically necessary (letter attached).
Please process this as an internal appeal under my plan's appeals process, confirm receipt in writing, and advise of the decision timeline and my right to external review.
Thank you,
[YOUR NAME]
[POLICY NUMBER]
[PHONE]
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BillSpar provides general legal information, not legal advice, and is not a law firm. Laws vary by state and change over time — verify anything critical with official sources or a licensed attorney in your state.
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