Insurance Denied Your Therapy Claim? Here's What to Do

Getting a denial letter from your insurance company after therapy can be disorienting and frustrating. The good news: most denials can be appealed, and many are overturned. Understanding why your claim was denied — and what to do about it — puts you back in control.

Why Insurance Companies Deny Therapy Claims

Denials fall into a few common categories. Knowing which one you're dealing with determines your best next step:

• Missing or incorrect information — The superbill lacked a required field such as the therapist's NPI number, diagnosis code, or CPT procedure code. These are often the easiest to fix.
• Medical necessity not established — The insurer decided the treatment wasn't medically necessary based on the diagnosis code or session frequency submitted.
• Out-of-network coverage limitations — Your plan may have limited out-of-network mental health benefits, or you may not have met your OON deductible yet.
• Timely filing deadline missed — Most insurers require claims to be submitted within 90 to 365 days of the date of service. If your therapist was late providing your superbill, this may have been the issue.
• Service not covered — The specific service billed (for example, couples therapy under some plans) may be excluded from your policy.

Your Explanation of Benefits (EOB) will include a denial reason code. Learn how to read it in our guide to understanding your EOB.

Step 1: Read the Denial Letter Carefully

The denial letter or EOB must state the specific reason for denial and your right to appeal. Under the Affordable Care Act, insurers are required to provide this information in plain language. Note the denial code, the reason description, and the deadline to file an appeal — typically 180 days from the denial date.

Step 2: Call Member Services Before You Do Anything Else

Before writing a formal appeal, call the member services number on the back of your insurance card. Ask the representative to explain the denial in plain language. Sometimes a simple administrative error can be corrected over the phone without a formal appeal. Take notes: record the date, the representative's name, and exactly what they tell you.

Step 3: Gather Your Documentation

To support your appeal, collect the following:

• The original superbill from your therapist (make sure all required fields are present)
• Your EOB showing the denial
• A copy of your insurance policy's mental health benefits section
• Any communication with your insurer about the claim
• A letter of medical necessity from your therapist, if the denial was for medical necessity reasons

For help getting a complete superbill, see our patient guide to superbills.

Step 4: Write Your Appeal Letter

Your appeal letter should be concise and factual. Include:

• Your name, member ID, and date of birth
• The claim number and date of service
• A clear statement of why the denial was incorrect
• References to your policy language that supports coverage
• A list of attached supporting documents

Under the Mental Health Parity and Addiction Equity Act, your insurer must cover mental health treatment on the same terms as equivalent medical or surgical care. If you believe your claim would have been approved for a comparable physical health service, state that explicitly in your letter.

For a complete step-by-step walkthrough of the appeal process, including sample language, see How to Appeal a Denied Mental Health Insurance Claim.

The Appeal Timeline

After you submit your appeal, insurers are required by law to respond within specific timeframes:

• Urgent care appeals — Response required within 72 hours
• Pre-service appeals (before treatment) — Response within 30 days
• Post-service appeals (after treatment, like most therapy claims) — Response within 60 days

If your internal appeal is denied, you have the right to an external review by an independent organization. This is often where denials get overturned. Your denial letter must explain how to request an external review.

What If the Appeal Is Denied Again?

If both your internal appeal and external review are unsuccessful, you can file a complaint with your state's insurance commissioner. The National Association of Insurance Commissioners (NAIC) has a directory of state regulators. You may also consult with a patient advocate or attorney who specializes in insurance disputes.

Don't give up after one denial. Statistics from the Kaiser Family Foundation show that the majority of appealed denials are overturned, but fewer than 1 in 10 patients actually file an appeal.

Preventing Future Denials

The best protection against future denials is verifying your out-of-network benefits before starting therapy. Call member services and ask specifically: What is my OON deductible? What is my OON coinsurance rate? Is prior authorization required for mental health visits? Also confirm with your therapist that every superbill includes all required fields — a single missing item is enough for an automatic denial.