How to appeal a health insurance claim denial, step by step

Two levels of appeal

When a health insurer denies a claim, you usually have two chances to change the decision.

1. Internal appeal. You ask the insurer to conduct a full and fair review of its own decision.

2. External review. If the insurer still says no, an independent third party reviews it. HealthCare.gov says that once your case goes to external review, the insurer no longer has the final say.

The insurer must tell you in writing why it denied the claim and how to dispute the decision. Start with that letter.

Step 1: Read the denial notice closely

Find and mark these five things:

• The claim. Date of service, provider and the service that was denied.

• The reason. Often one line, such as "not medically necessary," "not a covered benefit," "out of network" or "authorization absent."

• The plan rule it relies on. Some notices cite a policy section or clinical guideline.

• The deadline. How long you have to appeal.

• How to file. Address, fax, portal or form.

Sample denial notice · Northgate Health Plan (synthetic)

Service: physical therapy, 12 visits, 02/03 to 03/28 · Decision: denied after visit 6

Reason: services beyond visit 6 are not medically necessary based on the plan's clinical criteria for therapy.

You may request an internal appeal within 180 days of receiving this notice.

The reason is medical necessity for visits 7 to 12, not coverage of therapy as a whole. That tells you what the appeal needs to address: why the extra visits were needed.

Step 2: Know the deadlines

HealthCare.gov describes these rules for internal appeals:

• To file: within 180 days (6 months) of receiving the denial notice.

• Insurer's decision on appeal: within 30 days for a service you haven't received yet, and within 60 days for a service you already received.

• Urgent care: as quickly as your condition requires, and no later than 4 business days after the request. You can request an expedited appeal and an external review at the same time if your situation is urgent.

Your plan's notice may state different details, so use the deadline on your own letter and count from the day you received it.

Step 3: Build the appeal

What to send

HealthCare.gov lists the basics:

• the insurer's appeal form, or a letter with your name, claim number and health insurance ID number;

• any additional information you want considered, such as a letter from your doctor.

What makes it stronger

• Answer the stated reason. If the denial says "not medically necessary," the appeal should explain medical need, ideally in a letter from the treating provider.

• Use your plan documents. Quote the section of your policy or benefit summary that you believe covers the service.

• Add records. Clinic notes, test results, prior treatments that didn't work.

• Fix errors. If the denial came from a coding mistake or missing information, ask the provider to correct and resubmit the claim, and still file your appeal on time in case the fix doesn't go through.

A short appeal letter you can adapt

Re: Request for internal appeal · Member ID [number] · Claim [number]

I am appealing your decision dated [date] to deny [service] provided on [dates] by [provider]. The notice says the service was denied because [reason quoted from the letter]. I believe it should be covered because [one or two sentences]. Enclosed are [list: letter from Dr. [name], records dated [dates], plan section [number]]. Please review the claim and send me your decision in writing.

Keep the originals. HealthCare.gov suggests sending copies and keeping records of everything: the denial letter, your appeal, the documents you sent, and notes on each call (date, time, name and title of the person, and what was said).

You don't have to do it alone

HealthCare.gov says someone else can file the appeal for you, such as your state's Consumer Assistance Program, with your signed permission. Your doctor's office may also help, especially with the medical necessity letter.

Step 4: If the internal appeal is denied, ask for external review

Deadlines and cost

According to HealthCare.gov:

• To file: within 4 months of receiving the insurer's final denial.

• Standard decision: no later than 45 days after the request is received.

• Expedited decision: no later than 72 hours, or sooner if your condition requires it.

• Cost: free under the process run by the Department of Health and Human Services (HHS). Under an independent review organization or a state process, the charge can't be more than $25.

Who runs it

If your state has an external review process that meets federal standards, your state runs it. Otherwise HHS oversees it, or your plan contracts with an independent review organization. Your final denial letter should explain which applies and how to file.

Is the result binding?

HealthCare.gov says your insurer is required by law to accept the external reviewer's decision.

Different processes for some plans

These steps describe the rules HealthCare.gov sets out for private health insurance. Some decisions, such as Marketplace eligibility or premium tax credits, go through a separate Marketplace appeal. Medicare, Medicaid and some other programs have their own appeal processes and deadlines. Your plan documents or the denial letter will say which one applies.

Common denial reasons and where to start

• Not medically necessary. Ask the treating provider for a letter explaining why the care was needed.

• Prior authorization missing. Ask the provider's office whether it requested authorization, and when.

• Out of network. Check whether it was emergency care or care at an in-network facility; federal surprise billing rules may apply.

• Not a covered benefit. Compare the service with your plan's list of covered benefits and exclusions.

• Missing information or coding error. Ask the provider to correct and resubmit the claim.

Get help turning a denial into an appeal

EasyToDecode, launching soon, will read your denial letter or EOB, quote the reason and the deadline from the page, list what the appeal should address, and give you an editable appeal letter that cites those lines. See how it works or join the waitlist.