A denied claim is a decision, and decisions can be reviewed. Federal rules give people with most health plans two levels of challenge: an internal appeal to the insurer, and an external review by an independent third party whose decision the insurer must accept.
The process is procedural and deadline-driven. Knowing the sequence and the clocks is most of what it takes to use it.
Read the denial before you argue with it
Every denial comes with a notice stating the reason. The reason determines the argument, and arguing the wrong one wastes an appeal.
Common categories:
- Not medically necessary, meaning the plan concluded the service was not needed for your condition. This is the category external review was designed for.
- Experimental or investigational, a related clinical determination.
- Prior authorization not obtained, a procedural denial that is sometimes fixable retroactively.
- Out of network, which may be correct, or may be a case where the No Surprises Act applies. See in-network, out-of-network and surprise bills.
- Not a covered benefit, meaning the plan excludes it. Read the actual exclusion language rather than accepting the summary.
- Coding or billing error, which is extremely common and often resolved by a call to the provider's billing office rather than an appeal at all.
- Coverage terminated or premiums unpaid, an eligibility question rather than a clinical one.
Before filing anything, gather two documents and read them against each other: the explanation of benefits from your plan and the itemized bill from the provider. They frequently disagree, and the disagreement is often the whole problem.
The internal appeal
An internal appeal asks the insurer to reconsider its own decision.
- You have 180 days, roughly six months, from receiving the denial notice to file.
- File in writing. An oral appeal is accepted where the situation is urgent, but a written record serves you better.
- Decision deadlines: generally 30 days for a claim for a service you have not yet received, and 60 days for one you have already received. Urgent care claims are decided faster.
- You receive a written decision at the end of the process.
What makes an internal appeal effective is evidence, not indignation. Useful attachments include a letter of medical necessity from your treating provider, relevant records, the specific plan language you believe supports coverage, and published clinical guidelines where applicable. Ask your provider's office to help; they write these regularly and often have templates.
If the denial was for a service you have not yet received and delay would seriously jeopardize your health, you can request an expedited appeal, which must be decided much faster.
The external review
If the internal appeal is denied, you can take the matter to an independent reviewer outside the insurance company.
- You generally have four months from the date of the final internal denial to request it in writing. Some plans and state processes use different windows, so the notice you received governs.
- Standard reviews are decided no later than 45 days after the request is received.
- Expedited reviews are decided within 72 hours, or faster where the medical situation requires. In urgent situations you may request external review without having completed the internal process.
- The decision binds the insurer. If the reviewer decides in your favor, the plan is required by law to accept it.
- Cost is nothing under the federal external review process. Where a state process or an insurer-contracted independent review organization handles it, a nominal filing fee may apply.
Whether your review runs through a state process or the federal one depends on your state and on whether your plan is state-regulated or a self-funded employer plan. Your denial notice tells you which applies and where to send the request.
Where to get help
You do not have to do this alone, and several sources of help cost nothing.
- Your state's Consumer Assistance Program or health insurance ombudsman, where one exists, can help you file and can sometimes file on your behalf.
- Your state Department of Insurance handles complaints against state-regulated insurers and can tell you which process applies to your plan.
- The provider's billing and patient advocacy staff, especially for coding issues and letters of medical necessity.
- Your employer's benefits administrator, for a self-funded plan, since the plan sponsor rather than the insurer often controls the terms.
- The federal external review request line, which can send you the request form.
Habits that make appeals work
- Meet every deadline. Procedural dismissal is the most avoidable way to lose.
- Keep a call log with dates, names, reference numbers and what was said. Insurers keep their own notes, and disagreements about what was promised are common.
- Send appeals in a way you can prove, and keep copies of everything you send.
- Do not pay a disputed bill while the appeal is pending unless you have decided the charge is correct, but do stay in contact with the provider so the account is not sent to collections while the review is running.
- Appeal even if you think it is a long shot. Denials are sometimes reversed on the first internal appeal simply because a complete record was finally in front of a reviewer.
- Ask for the plan's clinical criteria used to make the decision. Plans generally must provide the internal rule or guideline relied upon, free of charge, on request.
What appeals cannot fix
An appeal challenges how the plan applied its terms. It does not rewrite the terms. If a service is genuinely excluded from the plan, an appeal is unlikely to produce coverage, and the more productive conversations are with the provider about cost, with a financial assistance office, or about a different plan at the next enrollment opportunity.
Appeal rights, deadlines, external review administration and consumer assistance programs vary by state and by plan type, and the plan documents and denial notice control. For your own situation, start with the notice you received, then your state Department of Insurance.
Related reading: deductible, copay, coinsurance and out-of-pocket max and the ten essential health benefits and free preventive care. You can also request health insurance quotes to get connected with licensed carriers and agents offering plans in your area.