A denial is a notice, not a verdict.
- "Denied means final." The notice explains how to appeal, and some decisions can go to external review.
- "Calling the plan stops the clock." Not necessarily, and neither does a corrected claim.
- "HR can get it overturned." The plan decides through its own process.
- "The bill waits while I appeal." Collections aren't automatically paused.
- "HR needs my medical records." It doesn't, and shouldn't have them.
Get the employee to read the reason on the notice, write down the appeal deadline, and keep the denial with the matching explanation of benefits.
Stay out of the clinical detail. Claim and medical information belongs in a secure channel between the employee, the provider, the plan and, if they want help, us. For client companies we help with claims advocacy, but we can't promise payment and we don't replace the plan's formal appeal process.
The reason on the notice tells you who can fix it.
Missing or incorrect information
A paperwork problem.
The employee asks the provider's office and the plan exactly what needs fixing or adding. A corrected claim may settle it, but the appeal clock keeps running.
Eligibility or coverage dates
Check the enrollment record first.
Compare enrollment records against coverage dates. HR can do the most here: confirm the election was accepted and the carrier shows the right effective date, and send it to us if not.
Authorization or network
A rule the plan applied before paying.
The employee should find out which rule the plan applied and whether an exception or review exists. Our network guide helps them check before the next appointment.
Medical necessity or an exclusion
The plan language matters most.
The employee asks the plan for the exact provision it relied on and the appeal instructions, and asks the treating clinician for supporting information. HR doesn't need to see any of it.
A note for the next time it happens.
Sample note to employees: "If a health claim is ever denied, keep the denial notice and the explanation of benefits together and look for two things: the reason, and the deadline to appeal. A phone call or a corrected claim won't necessarily stop that deadline, so write it down. You never need to send medical details to HR. If you'd like help, tell [HR contact] the claim number and we'll connect you with our benefits broker through a secure channel. Meanwhile, ask the provider's billing office when payment is due."
What to have ready, and when to call us.
Have ready
Your side: the employee's enrollment record and coverage effective date, the SBC and plan documents, whether the plan is fully insured or self-funded, the carrier's member services contact, and a secure way to send claim details to us. Their side: the claim number, date of service, denial notice, latest EOB, the plan language at issue, and a call log with names, dates and reference numbers.
Call us right away when
The denial is about eligibility or coverage dates. The deadline is close, or the notice seems to allow less time than the employee's rights do. The care is urgent and a faster review may apply. Several employees hit the same denial, which can point to a setup problem with the plan or the enrollment records.
Time limits worth knowing.
Many group health plans allow 180 days or more to file an internal appeal. Still, the notice and the plan's rules control, so read both. Urgent cases can qualify for expedited handling, and qualifying decisions can go to external review under the applicable rules, though not every denial can.
What HR teams ask us about denials.
Should HR call the insurance company for the employee?
Usually the employee or their provider makes that call, since the claim and medical details are theirs. HR can point them to the contact, the reason and the deadline, and we can step in on claims advocacy through a secure channel.
Where can an employee get help outside the plan?
It depends on the plan type. Washington's Office of the Insurance Commissioner helps with plans under its authority and can refer other questions to the right agency. Many self-funded plans sponsored by private employers fall under the U.S. Department of Labor instead, and public-sector and church plans may follow other rules.
Can an eligibility denial be our mistake?
It can. If the enrollment record, the carrier's records and payroll deductions disagree, send it to us, since we handle carrier changes for client groups. Our new-hire guide covers confirming enrollment up front, and our enrollment platform keeps the records in one place.
Official references.
HealthCare.gov on internal appeals and external review, the U.S. Department of Labor on filing a claim for health or disability benefits, and the Washington Office of the Insurance Commissioner. General information, not legal or tax advice.
Stuck on a denial?
Send us the claim number and the reason on the notice through a secure channel, and we'll help sort out the next step.