How to appeal a health insurance denial

Internal appeal, then external review

A denial is not the end. Most plans must let you appeal, and if the insurer says no again, many denials can go to an independent reviewer whose decision the insurer has to accept.

Step 1: Read the denial letter

Find the reason for the denial, the claim number, the date on the letter, and the deadline to appeal. Keep the envelope and your Explanation of Benefits too.

Step 2: File an internal appeal

Under HealthCare.gov rules you generally have 180 days (about 6 months) from the date you get the denial notice. Send the insurer a letter with your name, claim number and member ID, the reason you disagree, and any support such as a letter from your doctor. Keep copies of everything and note the date, time and name of anyone you speak with.

How fast the insurer must answer

Standard appeals: within 30 days for care you have not received yet, and within 60 days for care you already received.
Urgent cases are decided much faster. If waiting could harm your health, say so and ask for an expedited review.

Step 3: Ask for an external review

It is available for denials that involve medical judgment, including treatment the insurer calls experimental.
You generally have 4 months from the final denial to ask.
It costs nothing through the federal process, and other reviewers cannot charge more than $25.
A standard decision comes within about 45 days, and an expedited one within 72 hours or less.
The insurer is required by law to accept the reviewer's decision.

Tips that help

Ask your doctor for a short letter that says why the care is needed for you.
Ask the insurer for the rule or guideline it used and for the documents in your claim file. You can request them for free.
Stick to the facts and the dates. A calm, specific letter is easier to approve.

Want help writing your letter?
Upload your denial letter, explanation of benefits or bill to MyMedReply. It writes your appeal or dispute and cites the rules that usually apply. The draft is free; you pay only to copy it.
Write my appeal

Sources

This guide is general information, not medical, legal or insurance advice. Rules and deadlines vary by plan and state, so your denial letter and plan documents control. Medicare and Medicaid have their own appeal rules.