Your therapy claim was denied. Here’s what to do next.

Read the reason code first

Every denial comes with a reason, usually on the Explanation of Benefits or the denial letter itself. That code determines everything about what happens next, so start there rather than assuming the worst.

The common causes, and what each means

• Member not found or coverage inactive. Often a typo in the member ID, or a date of service that fell outside a coverage period. Verify the ID against the card and resubmit.
• Missing or invalid diagnosis code. The claim needs a valid ICD-10 code. This is a clerical fix.
• Wrong payer. Common with plans where mental health is carved out to a separate administrator. Empire Plan behavioral health, for example, is administered separately from the medical side, so a claim sent to the medical payer will bounce.
• Provider not recognized. Usually an NPI or tax ID mismatch, or a payer record that hasn't been updated.
• Duplicate claim. The same session submitted twice. No action needed if the first one processed.
• Timely filing. The claim arrived after the payer's filing window. This one is genuinely serious, because an expired claim often can't be recovered.
• Not medically necessary. The substantive denial, and the one that warrants a real appeal with clinical documentation.

What to do, in order

Call the number on your card. Ask them to walk you through exactly why the claim denied. Get the reference number for the call and the name of who you spoke with. This single step resolves more denials than anything else, because most are data errors visible on their screen.

Confirm whether it's a corrected-claim situation or an appeal. Administrative errors get fixed by resubmitting a corrected claim, which is faster and doesn't consume your appeal rights. Save the formal appeal for genuine coverage disputes.

If it's a real denial, file the appeal in writing and watch the clock. Plans set deadlines for internal appeals, and missing one can end the matter. Include the denial letter, your reasoning, and whatever clinical documentation your provider can supply.

Know that you have a second level. If an internal appeal fails, most plans offer external review. In New York, the Department of Financial Services handles external appeals for many plan types.

What we handle for you

Denials on our claims are our problem, not yours. Because we submit directly to NYSHIP and The Empire Plan rather than issuing superbills, we're the ones tracking claim status, catching errors, and resubmitting corrections. You shouldn't be spending an afternoon on hold about a wrong digit in a member ID.

It's also why we verify benefits before your first session. Most denials trace back to something that could have been caught up front — an inactive plan, the wrong administrator, a coverage detail nobody checked.

One thing not to do

Don't stop treatment because a claim denied. A denial is a billing event, not a clinical one, and it's very often reversed. If cost is a genuine concern while it's being sorted out, say so — that's a conversation worth having rather than a reason to disappear.

This article is general educational information, not insurance, legal, or financial advice. Coverage and costs depend on your specific plan. We verify your exact benefits for free before you begin.