Appealing a denied health insurance claim

A denied claim feels final. Often it is not. Health plans have a process for asking the insurer to look again, and for asking an independent reviewer if the answer stays no. This guide describes how that process generally works. The rules for your plan are in your plan’s documents and in the denial notice, and your insurer has the final word on its own steps.

This page is general information. It is not legal or medical advice.

Start with the denial letter

The denial arrives as a letter or an EOB, or both. Read it for these things:

• The reason. Common reasons include a service the plan treats as not covered, a service the plan considers not medically necessary, a missing prior authorization or referral, an out-of-network provider, missing information, or a billing code problem.
• The claim number, date of service and provider. You will need them in every call and letter.
• The deadline to appeal and where to send the appeal.
• Whether the case is urgent. Plans have faster routes when delay could seriously harm your health.

Highlight the reason and the deadline, and put the date on your calendar.

Check for a simple fix first

Some denials come from a clerical mistake. Call the provider’s billing office and ask whether the claim was coded and submitted correctly. If it was not, the office can often resubmit it. If a referral or prior authorization was missing, ask whether it can be added after the fact. Keep a note of every call.

If a fix is not possible or the office says the claim was right, move on to an appeal.

Gather what you need

Collect these in one folder:

• the denial letter and the related EOB
• your plan’s documents, including the summary of benefits and coverage and the full plan document or certificate
• any referral or prior authorization records
• your medical records for the visit or treatment, which you can ask the provider for
• your notes from calls with the insurer and the office

You can generally ask the insurer for a copy of your claim file and for the clinical guidelines it used to decide your case. Ask in writing and keep a copy of the request.

File the internal appeal

An internal appeal asks the insurer to review its own decision. The denial notice explains how.

1. Call the insurer and confirm where the appeal goes, whether a form is needed and how it will be acknowledged.
2. Ask your doctor for support. A letter explaining why the service is needed, and what could happen without it, is often the strongest part of an appeal.
3. Write a short letter. Include your name, member ID, claim number, date of service, provider, what you are appealing, why you think the decision is wrong and what you want the insurer to do.
4. Attach evidence: the denial, the doctor’s letter, the relevant records and plan language that supports your case.
5. Send it in a way you can prove, such as a method with tracking or a portal with a confirmation. Keep a copy of everything.
6. Follow up by phone after a reasonable wait and write down who you talked to.

Your provider’s office may also be willing to file an appeal on your behalf. Ask them.

If your situation is urgent, say so at the start and ask for an expedited appeal. The denial notice or the plan documents describe how those requests work.

What helps an appeal read well

Reviewers read many appeals. A short, factual letter that is easy to follow tends to do better than a long one. Put the reason you disagree in the first paragraph, and match it to the reason stated in the denial. For example, if the denial says a service was not medically necessary, the doctor’s letter should speak to that point directly, using your records. If the denial says the service is not covered, point to the plan language you rely on, with the page and section if you can.

While the appeal is pending

Ask the provider’s billing office whether it will hold the account while the appeal is decided, and ask for that answer in writing. Keep paying other bills as usual. If a bill is sent to collections during an appeal, tell the insurer and the billing office right away, and keep copies of what you send.

External review

If the insurer upholds its denial after the internal appeal, you can generally ask for an external review. An independent reviewer who does not work for the insurer looks at the case. For most plans, the reviewer’s decision is binding on the plan.

How to request an external review depends on your plan. It may run through your state or through a federal process. The final denial letter should explain the steps, the deadline and where to file. The federal marketplace site explains how appeals and external review work at healthcare.gov.

Different plans, different routes

Plans bought through the marketplace, plans offered by an employer, Medicare and Medicaid each have their own appeal routes and timelines. A self-funded employer plan may follow different rules than an insurance policy bought from a company. The notice you received should say which route applies to you. If it does not, ask your insurer or your HR benefits team.

Where to get help

• Your state’s insurance department can explain your rights and, for many plans, take complaints.
• Your employer’s HR or benefits team may be able to escalate a claim on an employer plan.
• A patient advocate or attorney can advise if the amount at stake is large.

For help reading the paperwork that comes before an appeal, see how to read an EOB, and for more on disputing charges, visit the Bills and coverage section.

Keep a record

Save every letter, confirmation and note. If the matter drags on, a dated list of what you sent and who you spoke to is the best evidence that you followed the process.

Quick answers

How long do I have to appeal a denial?

Your denial notice should state the deadline and how to file. It varies by plan and by state, so read the notice and act well before the date it gives. If you are close to the deadline, call the insurer and ask what your options are.

Do I need a lawyer to appeal?

Usually not. Many people file an appeal on their own with help from their doctor's office. If a large amount is at stake or the situation is complicated, you may want to ask a patient advocate or an attorney for advice.

What if I miss the deadline?

Call the insurer right away, explain what happened and ask whether any exception applies. Your state insurance department can also tell you what options exist. Do not assume the matter is closed until someone with authority has told you so.