How to Appeal a Denied Health Insurance Claim: Deadlines and Steps

To appeal a denied health insurance claim, file a written internal appeal with your plan within 180 days of receiving the denial notice, explain why the decision is wrong, and attach the evidence that supports you. If the plan says no again and the denial turned on medical judgment, or cancelled your coverage, you can usually ask an independent reviewer to decide, and your insurer has to accept that reviewer's decision.

A denial can be a refusal to pay for care you already had, a refusal to approve care you have not had yet, or the cancellation of your coverage. Under the federal rules for employer plans, paying only part of a claim also counts as a denial. This guide covers job-based plans and individual plans such as Marketplace coverage. Medicare has its own process: with Original Medicare, an appeal starts from the Medicare Summary Notice.

Why claims are denied

Reasons HealthCare.gov lists for an insurer refusing to pay include:

• The benefit is not covered by your plan.
• The provider or facility is not in the plan's network.
• The plan judges the service not medically necessary.
• The plan treats the service as experimental or investigational.
• You were not enrolled, or no longer eligible, on the date of service.
• The insurer is cancelling your coverage back to your enrollment date, called a rescission, claiming your application was false or incomplete.

The Department of Labor adds a common, fixable one: the plan simply needs more information. The reason shapes the evidence you need. A missing-information denial may need only the missing paperwork. A medical-necessity denial needs your doctor's clinical case.

What the denial notice must tell you

Under federal rules for employer plans, a denial notice must state the specific reason, point to the plan provision it relied on, say what extra information is needed and why, explain how to appeal, and describe your right to go to court. If the denial rests on medical necessity or an experimental-treatment exclusion, the plan must explain its clinical reasoning or offer that explanation free on request. Plans that are not grandfathered, meaning plans set up, or changed in certain significant ways, after March 23, 2010, must also give the denial code and its meaning and consumer assistance information. Your Explanation of Benefits, the statement your plan sends after it processes a claim, shows how the claim was handled; the guide to reading an Explanation of Benefits explains each line.

Step 1: Read the denial and get your file

Write down the date you received the notice. Your 180 days run from then. Next, gather what the plan used:

• Your claim file. An employer plan has to hand over, at no charge, copies of the documents, records and other information relevant to your claim when you ask. You can also ask it to name any medical expert it consulted.
• The codes. A plan that is not grandfathered must give you the diagnosis and treatment codes for a denied claim, with their meanings, on request.
• The plan's rules. For a job-based plan, read the Summary Plan Description, the official description of how the plan works, to see whether it allows more than 180 days and how many levels of appeal it has.

If the plan denied the claim for lack of information, the notice from an employer plan has to describe what is missing and why it is needed, so you know exactly what to send.

Step 2: File the internal appeal

An internal appeal asks your plan to reconsider its decision. Use the plan's appeal form if it has one, and add a letter. Under Labor Department rules, plans generally cannot charge you for filing a claim or an appeal. The appeal must go to a different reviewer from the one who denied the claim, and the new reviewer cannot be that person's subordinate. Where the dispute turns on medical judgment, the reviewer has to consult qualified medical professionals.

How fast the plan must decide

Type of claim	Plan's first decision (employer plans)	Decision on your appeal
Urgent care	No more than 72 hours	No more than 72 hours
Pre-service: approval for care you have not had yet	No more than 15 days, plus one 15-day extension in some cases	No more than 30 days
Post-service: care you already received	No more than 30 days, plus one 15-day extension in some cases	No more than 60 days

HealthCare.gov gives the same 30-day and 60-day appeal limits. Under the Labor Department rules, the time limits are calendar days, so weekends and holidays count, and an employer plan cannot take longer than its appeal deadline without your consent. If a plan requires two levels of appeal, each level generally gets half the time, so a pre-service appeal must be decided within 15 days at each level.

Urgent appeals

If the standard timeline could seriously jeopardize your life, your health or your ability to regain maximum function, ask for an expedited appeal and explain why. For employer plans, a physician who knows your condition can settle the question: once that physician tells the plan a pre-service claim is urgent, the Labor Department rules require the plan to handle it as an urgent care claim. HealthCare.gov says the decision must come as quickly as your condition requires, and employer plans must decide within 72 hours. In an urgent case you can also file for external review at the same time rather than waiting.

What to put in the appeal letter

• Your name, member ID, claim number, date of service and the provider's name.
• What you are appealing and what you want: pay the claim, or approve the treatment.
• Why the denial is wrong, answering the reason the plan gave and quoting the plan's own coverage wording where it helps.
• A list of everything you enclose.

Attach the denial notice, the Explanation of Benefits, a letter from your doctor explaining why the care is medically necessary, the relevant medical records, and the pages of your plan document you rely on. Send copies and keep the originals, along with a log of every phone call: the date, the person's name and what was said. The Labor Department's booklet suggests sending claim letters to a plan by certified mail, return receipt requested, which leaves a record of when the letter arrived and who received it. HealthCare.gov adds that the Consumer Assistance Program in your state can file an appeal for you. For a drug the plan does not cover, plans have a separate exceptions process, explained in the guide to formularies and drug tiers.

Step 3: Ask for external review

External review takes the decision away from your insurer. An independent reviewer looks at the case and either upholds the denial or decides in your favor, and the law binds the insurer to that result. It covers denials that involve medical judgment, denials of treatment as experimental or investigational, and rescissions.

• Deadline: request it within 4 months after you receive the final internal denial.
• Decision time: no later than 45 days after the reviewer receives a standard request, and no later than 72 hours, or sooner, for an expedited one.
• Cost: free if your plan uses the process run by the Department of Health and Human Services; otherwise no more than $25 per review.
• Who runs it: your state, if its process meets federal standards, or HHS. The final denial or your Explanation of Benefits names the organization.

Plans that are not grandfathered must offer external review by an independent party, and if such a plan fails to follow the internal claims rules, beyond a minimal slip, you can start external review without waiting. These extra rules apply only to plans that are not grandfathered.

If the appeal fails, and where to get help

For a job-based plan, the final denial must describe your right to have a court review the decision, and the Department of Labor says you may want legal advice at that point. You normally have to finish the plan's claims process before going to court. Its Employee Benefits Security Administration answers questions about employer plans at 1-866-444-3272 or askebsa.dol.gov. For a Marketplace plan, HealthCare.gov's help line is 1-800-318-2596.

Two situations call for checking your bill protections before you appeal. In most cases the No Surprises Act protects you from unexpected out-of-network bills for emergency room visits, air ambulance services, and non-emergency care at in-network hospitals, hospital outpatient departments and ambulatory surgical centers; see what the No Surprises Act protects you from. CMS takes questions about those protections at 1-800-985-3059. And if the denial stands, the guide to lowering a medical bill covers itemized bills, charity care and payment plans.

Frequently asked questions

How long do you have to appeal a denied claim?

180 days from the date you receive the denial notice. Employer plans must allow at least 180 days, and your Summary Plan Description may allow more.

Is a partly paid claim a denial?

Yes. Under the Labor Department's rules, paying anything less than 100% of a claim is a partial denial, so you can appeal the unpaid part.

What if your plan misses its deadline?

If a plan that is not grandfathered fails to follow the internal claims rules, beyond a minimal slip, you can start external review without waiting for the internal process to finish.

Does an external review cost money?

Not under the HHS-run process; other external review processes can charge no more than $25 per review. Under the Labor Department rules, plans generally cannot charge for filing an internal appeal.

Can you appeal a prior authorization denial before getting the care?

Yes. That is a pre-service appeal, which must be decided within 30 days. Under employer-plan rules, an urgent one must be decided within 72 hours.

Sources

• Internal appeals (HealthCare.gov)
• External review (HealthCare.gov)
• How to appeal an insurance company decision (HealthCare.gov)
• Filing a Claim for Your Health Benefits (September 2018) (U.S. Department of Labor, Employee Benefits Security Administration)
• Know your medical bill rights (CMS)
• Getting prescription medications (HealthCare.gov)
• Medicare & You 2027 (Centers for Medicare & Medicaid Services)