How to Appeal a Health Insurance Denial

Red flags and urgency levels

• UrgentSeek care today

  A denial for care you need urgently — ask for an expedited appeal, which has a much shorter timeline.

• SoonMake an appointment within days to a couple of weeks

  An appeal deadline approaching (often 180 days from the denial notice).

• SoonMake an appointment within days to a couple of weeks

  A denial reason that appears to be a coding or paperwork error rather than a coverage decision.

• MonitorKeep track and mention it at your next visit

  A denial you accept, where an in-network alternative is available.

• Insurers must explain in writing why a claim was denied or coverage ended, and how to dispute the decision.
• Common denial reasons include missing prior authorization, out-of-network care, coding or paperwork issues, a determination that care is not medically necessary, experimental or investigational treatment, a benefit not offered under the plan, or eligibility or rescission issues.
• Most plans provide an internal appeal, then an external review by an independent reviewer; the plan is required by law to accept the external review decision.
• File an internal appeal generally within 180 days (6 months) of the denial notice; the written decision after the internal appeal must explain how to request external review.
• Standard plan decision windows are about 30 days if the service has not yet been provided, and about 60 days if it has already been received. Urgent cases use a faster path.
• Your clinician’s office can often supply a letter of medical necessity and supporting records.
• This guide covers health plan coverage and claim appeals — not Marketplace eligibility appeals (for example, enrollment eligibility or premium tax credit decisions).

1. 1

   Read the denial letter or EOB for the reason, claim ID, appeal deadline, how to appeal, and any Consumer Assistance Program contact. Ask the plan in writing for the information used in the decision if you need it.

2. 2

   File an internal appeal within 180 days — use the plan’s forms or write with your name, claim number, and member ID; for urgent cases you may be able to file by phone, then confirm in writing. Keep copies and proof of delivery.

3. 3

   Attach supporting materials: a clinician letter of medical necessity and clinical notes or records. Keep originals, send copies, and keep dated call notes.

4. 4

   Track response clocks: about 30 days if care has not yet been received, or about 60 days if already received. For urgent appeals, plans must decide as soon as your condition requires and at least within about 4 business days, with written follow-up soon after any oral decision.

5. 5

   If still denied, request external review in writing generally within 4 months of the final internal determination; contacts are on the final denial or EOB. The external review decision is binding on the plan.

6. 6

   If waiting would seriously jeopardize your life or ability to regain maximum function, ask for an expedited appeal — you may be able to file internal and external review at the same time. Expedited external decisions are made as soon as possible and no later than 72 hours.

7. 7

   You may appoint an authorized representative (including a clinician) using the plan’s form when required.

8. 8

   Get help: contact a Consumer Assistance Program; if none is available, contact your state insurance department. For many job-based plans, you can also contact the U.S. Department of Labor Employee Benefits Security Administration (EBSA).

• “Can your office write a letter of medical necessity for this?”
• “Which clinical records support the appeal, and can they be sent directly?”
• “Was prior authorization required, and was it submitted?”
• “Is there an equivalent covered alternative if the appeal fails?”
• “Can you request a peer-to-peer review with the plan's medical director?”

• Appealing a Health Plan DecisionHealthCare.gov
• Internal AppealsHealthCare.gov
• External ReviewHealthCare.gov
• External Appeals Fact SheetCMS
• Marketplace External AppealsCMS
• How Can I Get Consumer Help If I Have Insurance?HealthCare.gov

• Understanding medical bills & EOBs
• Getting your medical records
• How to prepare for a doctor's appointment