Opening a letter that says your health insurer will not pay for a test, treatment, or prescription is stressful. The good news is that a denial is often just the first step in a process. Federal rules give most people with health insurance the right to challenge a denied claim, first with the insurer and then, in many cases, with an independent reviewer. This guide explains how the process works and how to make your appeal as strong as possible.
This article is general information and not legal advice. Rights and deadlines depend on your plan type and state, so check your denial letter and plan documents.
Why claims get denied
Understanding the reason on your denial letter shapes everything you do next. Common reasons include:
- Administrative errors. A typo in a member ID, a wrong billing code, a missing date, or a claim submitted after a filing deadline.
- Prior authorization not obtained. Many plans require advance approval for certain scans, surgeries, or medications.
- Not medically necessary. The insurer decides the service does not meet its clinical criteria.
- Out-of-network provider. The provider was not in the plan’s network, and the plan limited or refused payment.
- Experimental or investigational treatment. The plan classifies the therapy as unproven.
- Service not covered. The plan’s contract excludes the item or the benefit has run out.
- Pre-existing coverage questions or eligibility problems. Coverage may have lapsed or the member information may be wrong.
Some denials are legitimate. Many, however, are administrative and can be fixed with a corrected claim or a phone call.
Step 1: Read the denial letter closely
Your denial notice should state the specific reason, cite the part of the plan that supports it, and explain how to appeal and by when. It should also tell you how to request the clinical criteria used to make the decision. Highlight the deadline, because missing it can end your rights.
Write down the claim number, the date of service, the provider, the amount in dispute, and the denial reason code.
Step 2: Call the provider and the insurer
Before filing a formal appeal, call the provider’s billing office. Ask whether the claim was coded correctly and whether it was submitted with all required documentation. If there was an error, the provider can submit a corrected claim, which is often faster than an appeal.
Then call your insurer. Ask what exactly is needed to reverse the denial, and request a reference number for the call. Keep notes of every conversation, including names, dates, and what was said.
Step 3: Gather your evidence
A strong appeal is organized and specific. Collect:
- The denial letter and the Explanation of Benefits.
- Your plan’s Summary of Benefits and the full policy language about the service.
- Medical records relevant to the condition and treatment.
- A letter of medical necessity from your doctor explaining why the treatment is needed, what alternatives were tried, and what risks arise without it.
- Supporting clinical guidance, such as professional society recommendations or well-established treatment guidelines, if your doctor can provide them.
- Proof of prior authorization, if it was granted, or evidence that the insurer received your request.
Ask your doctor’s office for help. Many practices handle appeals every week and know which language insurers respond to.
Step 4: File the internal appeal
An internal appeal asks your insurer to take a second look. In most cases, a different reviewer who was not involved in the original decision must handle it, and for medical necessity denials a clinician with relevant expertise should be involved.
What to include
- A short cover letter with your name, member ID, claim number, and what you are appealing.
- A clear statement of why the denial is wrong, tied to the plan language and the medical evidence.
- Copies of all supporting documents.
Send it by a method that gives you proof of delivery, such as certified mail or the insurer’s online portal with a confirmation number. Keep a copy of the entire package.
Timelines
Plans must generally allow at least 180 days from the denial notice to file an internal appeal, though your plan may offer more. Insurers have set time limits to decide, often 30 days for services not yet received and 60 days for services already provided. If waiting could seriously jeopardize your health, you can request an expedited review, which usually requires a decision within 72 hours.
Step 5: Request external review if the denial stands
If your insurer upholds the denial, most plans must offer an external review by an independent organization that is not controlled by the insurer. Deadlines are typically four months from the final internal denial, but check your letter.
How it works
- You or your representative submit a request, often through the insurer or your state insurance department, depending on your plan type.
- The independent reviewer examines your records and the plan’s reasons.
- Their decision is generally binding on the insurer. If the reviewer sides with you, the plan must provide or pay for the service.
External review usually costs little or nothing for the patient, though rules vary. Self-funded employer plans follow federal procedures, while fully insured plans typically follow state processes. Your denial letter should explain which applies.
Step 6: Use other resources if you need them
- State insurance department. Most have a consumer assistance line and can explain your rights or take complaints.
- Employer benefits office. If you have a job-based plan, your HR department or benefits administrator may be able to advocate for you.
- Patient advocates and nonprofit helplines. Some hospitals and disease-specific organizations offer free assistance with appeals.
- Consumer assistance programs. Many states fund programs to help people appeal denials.
Tips that improve your chances
- Respond quickly. Deadlines are strict, and gathering records takes time.
- Be specific and factual. Cite policy sections and clinical facts rather than just expressing frustration.
- Stay polite but persistent. Reviewers are people who respond better to clear, organized submissions.
- Document everything. Keep a log of calls, copies of letters, and tracking numbers.
- Ask for the criteria. You are generally entitled to a copy of the guidelines the insurer used, free of charge.
- Keep your doctor involved. A strong letter from a treating physician is often the most persuasive document.
- Do not skip the appeal. A large share of people never appeal, even though many who do see decisions changed.
Special cases
Prior authorization denials
Ask your doctor whether a peer-to-peer review is available. This is a phone call between your physician and the insurer’s medical director and can resolve some denials without a formal appeal.
Prescription drug denials
Plans often have step therapy rules, requiring you to try cheaper drugs first. Your doctor can request an exception by explaining why the alternatives are unsuitable or have failed.
Urgent situations
If delay could harm your health, ask for an expedited internal appeal and, if needed, an expedited external review at the same time.
Medicare and Medicaid
These programs have their own appeal rules and timelines. The denial notice will explain the steps, and state Medicaid agencies or Medicare plans offer separate processes.
Frequently Asked Questions
How long do I have to appeal?
Most plans give at least 180 days from the date you receive the denial notice, but the exact deadline is in your letter. Do not wait.
Does appealing cost anything?
Filing an internal appeal is free. External review is free or low cost in most cases, though you may have to pay for your own copies of records.
Can my doctor appeal for me?
Yes, in many cases. You can also name a representative, such as a family member or advocate, by signing an authorization form.
What if my appeal is denied again?
Consider external review, a complaint to your state insurance department, and whether the provider can offer a payment plan or financial assistance for the unpaid amount.
Can I get care while I appeal?
Sometimes. For urgent situations, ask for an expedited appeal. If you proceed with treatment before a decision, you may be responsible for the bill if the denial is upheld, so discuss the risks with your provider.
The bottom line
A denial letter is the start of a conversation, not the end. Read the reason, check for simple errors, build a well-documented case with your doctor, and use both internal and external review when needed. Staying organized and meeting deadlines are the two habits that matter most.
