Guide
When Health Insurance Says No Or Makes You Wait
A practical guide to help you understand what’s behind delays and denials in health insurance coverage, ask informed questions, and figure out what to do next.
Primary audience: Patients and families
Additional audiences: Caregivers and others helping someone navigate health insurance
Topics Covered
- Understanding common health insurance terms related to delays, denials, claims, and appeals
- Asking questions to identify why a request or claim was delayed or denied
- Finding out what may be needed to resolve the problem
- Understanding options for escalating an unresolved issue
- Keeping track of records, deadlines, calls, documents, and decisions
- Preparing for the time, follow-up, and coordination that resolving a delay or denial may require
Why This Resource Matters
Health insurance delays and denials can be difficult to understand and resolve. People may need to determine why a request or claim was delayed or denied, understand unfamiliar insurance language, gather information, coordinate with healthcare providers, track deadlines, and determine what options are available if the problem is not resolved.
What's Inside
- Understanding insurance language
- Questions to understand a delay or denial
- Questions to help resolve the problem
- Appeals and external review
- Escalating unresolved issues
- Documentation, deadlines, and follow-up
Download the Resource
Formatted PDF
Includes graphics and layout.
Download PDF of When Health Insurance Says No Or Makes You Wait (PDF, opens in a new tab)Additional Resources from Other Organizations
- KFF: Claims Denials & Appeals in ACA Marketplace Plans, 2024 (opens in a new tab)
Provides data on how often claims are denied in ACA Marketplace plans, how often consumers appeal, and what happens when they do.
- American Medical Association: 2024 Prior Authorization Physician Survey (opens in a new tab)
Summarizes physicians’ experiences with prior authorization, including its effects on delays in care and patients.
- Centers for Medicare & Medicaid Services: Interoperability and Prior Authorization Final Rule (opens in a new tab)
Explains federal requirements designed to improve certain prior authorization processes and establish decision timeframes for impacted health plans.
Continue Learning
Keep exploring with another resource from the Center for Person-Centered Care.
Health Guide
Getting the Most from Your Health Insurance
This guide helps people understand their health insurance, ask informed questions, maximize their benefits, and navigate coverage decisions with confidence.
Explore Resource – Getting the Most from Your Health InsuranceCoverage delays and denials can be difficult to navigate. Don’t give up. You have the right to ask questions, understand the decision, and pursue your options.
The Health Guides, Visual Snapshots, and Clinical Practice Resources were reviewed by a physician for clinical accuracy and by other reviewers to improve readability, clarity, and ease of understanding.
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