How to appeal a health insurance denial

If your plan refuses to pay a claim or ends your coverage, you have the right to appeal. They have to tell you why, and how to dispute it. Two stages: an internal appeal inside the insurer, then, if that fails, an external review by an independent third party whose decision the insurer must accept.

Inside the insurer

They must notify you in writing and explain why: within 15 days if you were seeking prior authorization, 30 days for services already received, or 72 hours for urgent care. You then have 180 days from that notice to file. Use their forms, or write with your name, claim number, and insurance ID, and attach anything you want considered — a letter from your doctor is the usual one. Your state’s Consumer Assistance Program can file for you.

They must finish the internal appeal within 30 days if the service has not happened yet, or 60 days if it has. The decision comes in writing. If they still say no, that letter has to tell you how to request an external review.

Common reasons, all appealable: the benefit is not in your plan, the service was out of network, they called the treatment not medically necessary, they called it experimental or investigational, or they claim you are no longer eligible.

The independent review

Request it in writing within four months of the final denial. Denials that involve medical judgment, that call a treatment experimental or investigational, and coverage cancellations based on claimed misinformation can all go here. Standard review: 45 days. Expedited: 72 hours or less, depending on urgency. The reviewer’s decision binds the insurer. Federal process: no charge. Otherwise the fee is capped at $25 per review.

If waiting the standard time would seriously jeopardise your life or your ability to regain maximum function, file an expedited appeal, and you can start the external review at the same time as the internal one. A final decision has to come as quickly as your condition requires, and at least within four business days.

Keep the paper

Explanation of Benefits showing the denial. Your appeal request. Anything from your doctor. Any authorization letting someone file for you. Notes from every phone call: date, time, name, title. Send copies. Keep originals. This is the kind of pile that is easier if your records and letters already live in one place.

You can appoint a representative — your doctor, often — to file an external review. Your state’s Consumer Assistance Program or Department of Insurance can help with either stage.