Questions That Matter
When Health Insurance Says No Or Makes You Wait
Health Guide No. 9, Published August 2026
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
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When Health Insurance Says No Or Makes You Wait
Better healthcare depends on informed questions, engaged communities, and decisions that reflect people's needs.
This guide helps you understand what's behind delays and denials in health insurance coverage and what you can do next.
Understanding the Language
- Prior authorization: Permission from your health plan needed before certain care is covered.
- Request for additional information: Your health plan needs more information before making a decision.
- Expedited/urgent review: A faster review process when waiting for the standard timeframe could negatively affect your health or ability to function.
- Denial: A request for coverage or payment was not approved.
- Explanation of Benefits (EOB): A statement from your health plan showing how a claim was processed, including what was billed, what the plan paid, and what you may owe. It is not a bill.
- Appeal: A formal request asking your insurer to reconsider a decision about coverage or payment.
- Appeal deadline: The date by which you must submit an appeal or request for review.
- Internal appeal: An appeal reviewed by your health plan.
- External review: A review of certain health plan decisions by an independent party or organization.
Did You Know?
- Less than 1% of denied in-network claims are appealed.1
- About 1 in 3 appealed denials were overturned among HealthCare.gov plans in 2024.2
- Some denials are for administrative reasons, including missing information, duplicate or late claims, or use of an unapproved provider.3
- 93% of physicians reported that prior authorization delayed necessary care at least some of the time.4
- Some health insurance plans must make certain prior authorization decisions within 7 calendar days for standard requests and 72 hours for expedited requests.5
Sources
1-3. KFF: Claims Denials & Appeals in ACA Marketplace Plans, 2024 (opens in a new tab)
4. AMA: 2024 Prior Authorization Survey (opens in a new tab)
5. Centers for Medicare & Medicaid Services. CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) (opens in a new tab)
Questions to Ask Your Health Insurance Company
These are starting points. Not every question will apply. Focus on the ones that fit your situation.
Questions to Help Understand the Problem
- Why was this denied or delayed?
- Can you explain the reason in plain language?
- Is this a coverage issue, a prior authorization issue, or a claims issue?
- Is any information missing, incorrect, or miscoded?
- What criteria were used to make this decision?
- When did you receive and start reviewing the request?
- Did you receive my appeal and what is the tracking number?
- What is the deadline for a decision?
- Can you send me this information in writing?
Questions to Help Resolve the Problem
- What specifically must happen for this to be approved?
- Can my provider correct the request or supply records supporting an appeal?
- Can this be expedited?
- What can I do if you miss the decision deadline?
- What are my appeal options and deadlines?
- Is this denial eligible for an external review?
- What should I do next, and when should I follow up?
- Is there a case manager or someone else who can help coordinate or escalate this issue?
- Where can I get help if this is not resolved?
Resolving a Delay or Denial Can Take Time and Effort
Trying to resolve a denial or delay may require:
- Understanding insurance language
- Obtaining records and supporting documentation
- Coordinating with healthcare providers
- Making calls, completing forms, tracking deadlines and following up
- Keeping records of calls, documents, and decisions
If the Problem Isn't Resolved
If you need to further escalate, consider:
- Filing an internal appeal. Some employer health plans have two internal appeal levels.
- Requesting an external review. For eligible denials, a reviewer outside your health plan can reconsider a decision. Your insurer must follow the reviewer's decision. Ask how to apply and by when.
- Contacting your state insurance department. It may be able to answer questions, explain your rights, or help with a complaint.
- Checking with your employer. If you have job-based coverage, your benefits office may be able to help.
- Seeking consumer assistance. Depending on where you live and your type of coverage, programs may be available to help you understand and navigate your options.
Healthcare for people who live in the real world, not in a medical chart.
Coverage 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.
Note: This guide reflects the U.S. healthcare system and is a living document that continues to evolve.
Prepared by Cynthia Overton, PhD
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.
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.
Coverage 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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