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Part of: Understand your denial

Guide · the basics · 4 minute read

The kinds of no: claim denial, prior authorization, pharmacy rejection, coverage ended

Six different ways a plan can say no, where each one shows up, and which clock and rules go with it, so you know what you are actually holding.

Applies to: Any coverage

Key points

  • A plan can say no before care (prior authorization), after care (a claim denial), at the pharmacy counter, or by ending your coverage.
  • A rejected claim and your normal cost share are different again, and are not decisions you appeal.
  • Each kind has its own clock, so name the kind before you count days.
On this page 6

“No” comes in several kinds, and each kind has its own clock and its own next step. Before you count any days, name the kind you are holding.

What this means

A claim denial (after care)

You had the care or bought the drug, and the plan refused to pay all or part. It arrives as an Explanation of Benefits or a denial letter. In a private group plan the plan generally has up to 30 days to decide a claim for care already received. An appeal can be filed for at least 180 days after you receive the notice (check the date on your notice, which controls).

A prior authorization refusal (before care)

Your plan or its review company said no to approving a service in advance. Prior authorization is a “pre-service claim” under private plan rules, so a decision is due no later than 15 days (one 15-day extension is possible), or 72 hours if urgent. Medicare Advantage, Medicaid and Children’s Health Insurance Program (CHIP) plans have a newer 7-day standard rule for most non-drug services. Employer and Marketplace plans do not.

A pharmacy rejection (at the counter)

The pharmacy tells you the drug will not go through. The cause may be a prior authorization requirement, a drug missing from the plan’s list (the formulary), a quantity limit, a step therapy rule (try a cheaper drug first), or a coverage problem. A message on a screen is not a written decision. In a Medicare drug plan, the first decision is called a coverage determination, due within 72 hours, or 24 hours if expedited, and an exception request starts the clock when the plan receives your prescriber’s supporting statement.

Coverage ended (a termination)

The plan said you are no longer covered. A plan can cancel coverage back in time (a rescission) only for fraud or an intentional misrepresentation of a material fact, and only after at least 30 days of advance written notice. A rescission can be appealed and taken to external review. Cancelling back in time for unpaid premiums is not a rescission. In Medicaid, the state must generally send notice at least 10 days before it ends or cuts coverage, with a few listed exceptions.

A rejected claim (the claim never got decided)

A mistake or missing piece stopped the claim from being processed. A provider usually fixes and resends it. See denied, rejected, or just your share.

Your normal share (not a decision at all)

Deductible, copayment or coinsurance. Nothing was refused. Check the math and move on, or ask for reprocessing if it looks wrong.

What to do

  1. Look at where it came from. Pharmacy screen, statement, letter, portal message or phone call.
  2. Look for the words “before”, “after” and “ending.” They sort most notices into the kinds above.
  3. Ask for it in writing if you only have a phone call or a screen. Use the request for a denial in writing or the pharmacy rejection script.
  4. Start the matching clock with the decision clock and the deadline calculator.
  5. Check urgency. If waiting would harm your health, use the urgent appeal triage tool.

What the plan may say, and what to say back

“We do not need to approve it. Your doctor just has to submit it.” Ask: “Has a request been submitted? What is the reference number and the date a decision is due?”

“The pharmacy cannot fill that.” Ask the pharmacy for the reason code and whether it can give a short supply while your doctor sorts it out. The Arthritis Foundation suggests asking for a hold or partial fill. Then ask your doctor’s office to contact the plan.

“Your coverage ended last month.” Ask for the termination notice and the reason in writing, and ask whether it is a cancellation back in time.

The rule

A private plan may cancel coverage retroactively only for fraud or an intentional misrepresentation of a material fact, and only after at least 30 days’ advance written notice. That cancellation is an adverse benefit determination you can appeal. Source: Code of Federal Regulations (CFR) Title 45, section 147.128.

Watch for

  • Silence can be a denial. If a plan does not decide in time, Medicare drug plans, Medicare Advantage plans and Medicaid managed care plans treat that as a denial that can be appealed. See when the plan is silent.
  • Approved, then denied. A Medicare Advantage plan may not deny for lack of medical necessity after it approved a service, and may reopen the approval only for good cause or reliable evidence of fraud or similar fault. See approved, then denied.
  • Marketplace termination versus eligibility. A health plan ending your coverage goes to the plan’s appeal. A Marketplace eligibility decision goes to the Marketplace appeal, usually within 90 days of the eligibility notice.
  • Care that is ending. Notices about hospital discharge or ending nursing or home health services have deadlines measured in hours or days. See the first 48 hours.

What next

Sources

Official and primary sources used on this page. Checked 2026-11-12.

  1. 29 CFR 2560.503-1, claims procedure (timing for urgent, pre-service and post-service claims) — Electronic Code of Federal Regulations
  2. 45 CFR 147.128, rules regarding rescissions — Electronic Code of Federal Regulations
  3. 42 CFR 423.568, Part D coverage determination timeframes — Electronic Code of Federal Regulations
  4. 42 CFR 431.211, advance notice of Medicaid adverse actions — Electronic Code of Federal Regulations

What next

Letters and scripts

  • Letter or script

    Phone script: pharmacy rejection

    What to ask at the pharmacy counter and then your plan when a prescription is rejected, so you learn why and what to send.

  • Letter or script

    Ask for a denial in writing

    A written request for a proper denial notice when the plan has only told you by phone that it will not approve or pay. It lists what the notice must contain so you know your reason and your appeal rights.

  • Letter or script

    Appeal: prior authorization denied

    Asks your plan to reverse a refusal of approval before care, to say what standard it applied, and to decide with a clinician in the right field.

Tools

  • Tool

    Denial reason finder

    Match the wording on your letter to a denial reason, see who must act first, and open the right playbook.

  • Tool

    Decision clock

    Check whether your plan has taken longer than the law allows to decide, and what you can do if it has.

  • Tool

    Urgent appeal triage

    See whether you can ask for a fast decision, what your doctor must say, and who to call today.

Checklists

Related guides

  • Guide

    Denied, rejected, or just your share of the cost

    Three things that look alike on a statement or a bill: a denial, a rejected claim and your normal share of the cost. Learn how to tell them apart and who has to act.

  • Guide

    Prior authorization denied

    What to do when your plan refuses to approve a service before you get it. Also which decision deadlines apply to employer, Marketplace, Medicare Advantage and Medicaid plans.

  • Guide

    Prior authorization stuck

    What to do when your plan has not answered a prior authorization request, how long each type of plan has, and how to push a stalled request forward.

  • Guide

    When the insurer misses its deadline or goes silent

    If your plan does not decide your claim or appeal on time, you may be able to skip ahead to external review or court. Here is what the rule says, its small-mistake exception, and what to do in practice.

  • Guide

    Drug not covered: formulary exceptions

    How to ask your plan to cover a drug that is not on its formulary. See who supplies the medical reasons and the Medicare drug plan deadlines.

  • Guide

    When coverage is cancelled retroactively

    What federal rules say about a plan cancelling your coverage back in time. A rescission is different from a cancellation for unpaid premiums. Here is how to appeal.

  • Guide

    Approved, then denied

    What to do when your plan approved a service or said it was covered, then refused to pay the claim. Includes what Medicare Advantage plans may not do.

  • Guide

    How to get an expedited appeal

    When waiting could seriously harm your health, you can ask for a fast appeal, decided in 72 hours or less, and ask for independent review at the same time. Here is how to ask and what your doctor can do.

Denial reasons

  • Denial reason

    Prior authorization denied

    Your doctor asked the plan to approve care in advance and the plan said no. The clocks are short, and your doctor can ask for a doctor-to-doctor call. Independent external review is open if the reason is medical and your plan is not grandfathered.

  • Denial reason

    No prior authorization

    The plan says approval was needed before the service and was not obtained. Find out whether approval was really required, who was supposed to ask, and whether getting it was impossible. Your provider often has to act.

  • Denial reason

    Drug not on the formulary

    The drug your doctor prescribed is not on the plan's list of covered drugs. You can ask for an exception. Your prescriber will need to state why this drug, and not the covered ones, is right for you.

  • Denial reason

    Coverage rescinded

    Your plan says it is cancelling your coverage retroactively, as if it never existed, because of your application. Federal rules allow that only for fraud or an intentional misrepresentation of a material fact, with 30 days' written notice.

  • Denial reason

    Care is ending

    Hospital, rehab, nursing home or home health care ending? Medicare: call the reviewer on your notice by noon the day after you get it, or 1-800-MEDICARE (1-800-633-4227). Medicaid or job-based plan: see What to send.

This page is general information, not legal or medical advice. Your notice, your plan document and the law that applies to your coverage control.

Sources last checked . Found a mistake? Report it.