TriangleInsurance denials and appeals
The deadlines, what counts as urgent, who can file, and what it costs.
This is not clinical evidence and not medical advice. It does not replace your care team. Discuss anything here with your clinician before you act on it. Product questions are on the FAQ.
How long do I have to appeal a health insurance denial?
180 days from the denial notice for the internal appeal. If that fails, four months from the final denial to request an external review.
How long does the insurer have to decide my appeal?
Internal: 30 days if you have not had the service yet, 60 days if you have. External: 45 days standard, 72 hours or less if it is expedited.
What is an external review?
An independent third party looks at the denial. The insurer has to accept that decision. Medical-judgment denials, “experimental or investigational” denials, and coverage cancellations for claimed misinformation can all go here.
What if my situation is urgent?
If the standard timeline would seriously jeopardise your life or your ability to regain maximum function, file an expedited appeal and start the external review at the same time. A final decision has to come as quickly as your condition requires, and at least within four business days.
Can my doctor file the appeal for me?
Yes. You can appoint a representative, such as your doctor, for the external review. Your state’s Consumer Assistance Program can also file the internal appeal.
Does an appeal cost anything?
Federal external review: no charge. State process or an independent review organisation: capped at $25 per review.
What should I keep?
The Explanation of Benefits, a copy of your appeal, anything from your doctor, any authorization for someone to file, and dated notes of every call with the person’s name and title. Send copies. Keep originals.
Can a denial for an experimental treatment be appealed?
Yes. “Experimental or investigative” is appealable internally, and it is one of the categories eligible for external review.
See how Triangle keeps your records and letters in one place →
Sources
- HealthCare.gov: How to appeal an insurance company decisionRight to internal appeal and external review; insurer must explain denials and how to dispute them.
- HealthCare.gov: Internal appeals180 days to file an internal appeal; decided within 30 or 60 days; expedited decisions within 4 business days; Consumer Assistance Programs can file; documents to keep; experimental/investigative denials can be appealed.
- HealthCare.gov: External ReviewExternal review within 4 months; decided within 45 days or 72 hours expedited; binding; eligible denial types; representative may file; no charge under federal process, otherwise capped at $25.