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Submitting a health insurance claim may seem easy enough. However, numerous Americans in 2026 lose money, encounter payment delays, or experience claim denials due to basic mistakes in filing their claims. No matter whether you have an ACA Marketplace plan, group coverage provided by your employer, or Medicare – learning how to avoid the most common claim mistakes will help you to save significant amounts of money and reduce stress when dealing with healthcare procedures.
Here are the 10 main reasons why you might have trouble with health insurance claims and how to fix them.
Why Claim Denials and Mistakes May Be Really Expensive in 2026
The cost of medical treatments continues to grow every year. A single denied claim might cost you tens of thousands of dollars and negatively affect your credit rating. Each day, millions of claims are submitted to various insurance companies, and even a minor mistake might trigger a denial process or affect the total amount of the insurance reimbursement.
Thus, learning about the most frequent mistakes might prove to be very useful.
1. Submitting Claims Past the Deadline
Late claim submission is one of the most frequent reasons for denials or delays. As a rule, you must submit your claims within 30 to 90 days (sometimes – up to a year).
How to avoid it?
Submit claims as early as you can, immediately after the procedure or as soon as you receive the corresponding bill.
Utilize the opportunities offered by your mobile app or insurer’s website for quick and immediate claims filing.
Set calendar notifications in case you have pending bills to file.
Make copies of each of the submitted forms (claims and explanations of benefit) and store them.
2. Incomplete or Incorrect Documentation
As you probably know, health insurance companies are very meticulous when it comes to required paperwork.
Mistakes in providing your personal data, wrong procedure codes, or incomplete medical records might cause a rejection.
How to avoid it?
Always obtain itemized bills from your healthcare providers.
Double-check that all of your personal data – including your name, address, date of birth, and insurance ID number – are correct.
When possible, ask providers to send claims electronically.
Keep a separate physical or virtual folder to store all of the necessary papers.
3. Using Out-of-Network Healthcare Providers Unintentionally
It often happens that a person assumes that a specific specialist is included in his/her plan only to find out later that this particular provider works exclusively outside of the network and, thus, charges significantly more.
How to avoid it?
Never use any services of providers until you have checked your plan’s list of covered specialists.
Make a double check just before the planned treatment.
In emergency cases, even out-of-network providers must accept in-network rates.
4. Disregarding or Failing to Understand Explanations of Benefit Forms
It is crucial to understand how to read the explanation of benefit form correctly, as most patients make serious mistakes in this regard.
They simply throw away the forms or fail to understand the meaning of different items on the list.
How to avoid it?
Study each of the received explanations of benefit carefully (within 30 days after its receipt).
Look through the list to compare with your original bill.
Know what ‘allowed amount’, ‘patient responsibility’, and ‘denied services’ mean and how they influence the final total.
Contact your insurance company immediately to clarify things if you see anything suspicious.
5. Ignoring the Need to Get a Prior Authorization
If you are going to use expensive procedures, prescription drugs, certain medications, or undergo a surgical procedure, then, prior authorization is required beforehand.
Not having prior authorization results in denials in most cases.
How to avoid it (or fix it)?
Always discuss with your physician or his/her staff what additional measures are required.
If you have no experience with obtaining a prior authorization yourself, then ask a professional to deal with it on your behalf.
Collect all of the evidence required by the insurer to consider your claim and provide it immediately.
6. Refusing to Appeal Denied Claims
Appeals usually increase your chances of receiving a favorable decision by 40 to 60 percent. Nonetheless, most patients refuse to appeal and lose their rights to compensation.
How to avoid it (or fix it)?
Study the refusal letter carefully to learn about deadlines and required documentation.
Write your complaint to your insurer to request reconsideration.
Support your request with letters from your doctor and other medical specialists and documentation.
Do not hesitate to seek independent evaluation if there are any chances for success.
7. Failing to Protect Yourself Against Balance Billing and Surprises
Balance billing occurs when you have to pay additional money to your healthcare provider despite the fact that your treatment was insured. Unfortunately, even when using an insured specialist, you may be asked to pay for part of the procedure or treatment.
How to avoid it?
Learn more about your rights according to the No Surprises Act to avoid such cases.
Talk with the medical provider and reach an agreement regarding the price.
Always choose the in-network providers and try to get an estimate beforehand for non-emergency cases.
8. Coordination of Benefits Errors
Sometimes, coordination of benefits becomes the key problem that prevents patients from submitting their claims successfully. If you have several health insurance plans and use them interchangeably or simultaneously, you have to be careful about the order of using the plans.
How to avoid it?
Find out which of the plans serves as the primary and secondary insurance and in what cases.
Be sure to provide both ID numbers of your primary and secondary insurance providers.
Let the primary provider process the claim, and then forward the explanation of benefit form to the secondary insurance plan provider.
9. Mistakes in Prescription Drug Claims
Wrong choice of the pharmacy (the out-of-network pharmacy), absence of mail order prescriptions, and choice of non-formulary drugs usually result in denials or increase the final price.
How to avoid it?
Before filling the prescription, study the plan’s drug formulary.
Try to use a preferred pharmacy to obtain medication, especially in case of long-term conditions.
Consider mail-order prescriptions whenever possible.
10. Failing to Keep Adequate Paperwork and Records
Proper recordkeeping is always very important if you want to make sure that your appeals are successful and that you do not overpay.
Best practices?
Store all of your paperwork in digital formats.
Take pictures of your bills and any documents related to the procedures or tests.
Accurately track the medical expenses for possible tax deductions if you are self-employed.
Additional Tips to Avoid Claim Mistakes
Visit your insurer’s member portal regularly.
During Open Enrollment periods, choose those insurers who have good reputation regarding customer service quality.
Discuss possible insurance claims problems with professionals from your physicians’ office; they can help with many claims.
Consider opening a health savings account or flexible spending account.
Review your Summary of Benefits and Coverage (SBC) annually.
Conclusion
The majority of claims mistakes happen accidentally and might be easily avoided. To make sure that you never face problems in the future, take the following steps:
verify whether a particular provider belongs to your plan
obtain prior authorizations before expensive treatments
submit complete documentation
review explanations of benefit forms carefully and
appeal claim denials when it is necessary.
Real-life examples show that this advice works quite well. Sarah in Colorado appealed the refusal to cover her surgery (a total of $12,000) and succeeded due to the support of her surgeon. The Johnson family in Florida managed to recover their overpayment ($1,800). And a young man in California was deprived of the opportunity to use his health plan due to his condition.
FAQ
1. How long should I wait with submitting my claim?
As a rule, the period of claims submission ranges between 30 and 90 days. Still, some plans may allow one-year submission periods.
2. What should I do if I receive a denial notice?
You need to appeal this decision.
3. What is an explanation of benefit?
This is a form containing detailed information regarding the insurance payments, denials, and patients’ responsibilities.
4. Does the No Surprises Act protect me from balance billing?
Yes, this act is designed specifically to help avoid such situations.
5. Should I submit claims myself or ask my doctor to perform this task?
Whenever possible, use the services of your physician.
6. Where should I find the information whether prior authorization is required?
You may find it in your plan’s summary of benefits and coverage.
7. Can I appeal denials several times?
Of course. Every insurer must provide a possibility to file an internal appeal, as well as an external one.
8. Which papers should I keep for further claims submissions?
All itemized bills, explanations of benefit forms, authorization numbers, doctor’s notes, and other documentation.
9. Are cheap health insurance plans more likely to reject claims?
Yes, they tend to deny claims more often and have smaller coverage limits.
10. How can I protect myself against claims problems?
Verify providers and obtain prior authorizations, submit all of the necessary documentation and read explanations of benefits carefully.