How to Appeal an Insurance Denial

An internal appeal is your first formal step to challenge an insurance denial. It's called "internal" because your insurer reviews it themselves (rather than an outside body reviewing it).

Steps to file an internal appeal:

• 1. Gather your documents: Collect your EOB, policy documents, medical records, and any other relevant documentation
• 2. Check your deadline: Review your EOB for the appeal deadline (typically 180 days for commercial insurance)
• 3. Prepare your appeal letter: Write a clear letter explaining why you believe the denial is wrong (we cover this more below)
• 4. Submit your appeal: Send your letter and supporting documents to the appeals address listed on your EOB or insurance ID card
• 5. Keep copies: Make copies of everything you send and save them for your records
• 6. Follow up: If you don't hear back within 30 days, contact your insurer's appeals department to check status

How to submit: You can usually submit by mail, fax, or online through your insurer's member portal. Some insurers now accept appeals through secure email. Check your EOB for preferred submission methods.

Timeline: Insurers typically must respond to appeals within 30 days for standard reviews or 72 hours for expedited reviews of urgent care denials.

The stronger your documentation, the stronger your appeal. Here's what to include:

Essential documents:

• EOB: The original denial notice explaining the specific reason for denial
• Claim information: Details about the service (date, provider, procedure code, diagnosis code)
• Policy documents: Relevant sections of your insurance policy showing the service should be covered

Supporting medical evidence:

• Letter of Medical Necessity: From your treating physician explaining why the treatment was medically necessary
• Medical records: Documentation from your doctor supporting the diagnosis and need for treatment
• Peer-reviewed studies: Research supporting the treatment's effectiveness for your condition
• Clinical guidelines: Evidence from authoritative medical organizations recommending the treatment
• Prior successful treatments: Documentation of other treatments you've tried and why they didn't work

Additional supporting materials:

• Your appeal letter explaining your case
• Insurance commissioner complaint (if you're filing concurrently)
• Previous correspondence with your insurer
• Pre-authorization letter (if the service was pre-authorized)

Organize and present clearly: Number your pages, create a cover letter summarizing what's included, and use tabs or markers to highlight key sections.

A Letter of Medical Necessity is a formal document from your healthcare provider stating that a specific treatment, medication, or service was medically necessary for your condition. It's one of the most powerful documents you can include in an appeal.

What it should include:

• Your name and date of birth
• The specific service or treatment being discussed
• The date the service was provided (or is planned)
• Your diagnosed condition requiring the treatment
• Why this specific treatment is necessary for your condition
• Any other treatments you've tried and why they were ineffective
• Reference to clinical guidelines or studies supporting the treatment
• The physician's professional opinion that the treatment is reasonable and necessary
• Physician signature and contact information

How strong should it be? The more specific and detailed, the better. Generic letters are less effective than letters that address the insurance company's specific concerns (as stated in your denial reason).

Who should write it? Ideally, the treating physician who recommended the treatment. If that's not possible, another physician with knowledge of your case can write it.

Timeline: Request this letter soon after receiving your denial. Ask your doctor for a turnaround time of 5-7 business days.

Asking your doctor for a support letter should be straightforward, but here's how to approach it strategically:

Steps to request a Letter of Medical Necessity:

• 1. Contact the right person: Call your doctor's office and ask to speak with the office manager or medical assistant who handles insurance matters
• 2. Explain the situation: Tell them your claim was denied and you need a letter of medical necessity for your appeal
• 3. Be specific: Provide the exact service, the denial code, and what the insurance company said (e.g., "they said it's not medically necessary")
• 4. Request a deadline: Ask when the letter can be completed. Most offices can turnaround in 5-10 business days
• 5. Offer to help: Provide your contact information and offer to answer any questions or provide additional records
• 6. Follow up: If you don't receive it within the agreed timeframe, call to check on status

Sample request (you can use this as a guide):

What to do if your doctor refuses: Most doctors will write the letter if the service was legitimate and recommended by them. If they refuse, ask why and address their concerns. If they still refuse, consider getting a second opinion from another physician.

A peer-to-peer review is a conversation between your doctor and the insurance company's medical director (both physicians) to discuss whether the denied treatment was medically necessary.

Why it's powerful: Insurance medical directors often respect the professional judgment of treating physicians. A conversation between two doctors can be more persuasive than written documentation alone.

How to request one:

• Ask your provider: Contact your doctor's office and ask if they'll participate in a peer-to-peer review with your insurer
• Or contact your insurer: Call your insurer's appeals department and specifically request a peer-to-peer review as part of your appeal
• Be specific: Explain that you want your treating physician to speak directly with the insurance company's medical director

What happens during the call:

• Your doctor and the insurance company's medical director speak by phone (usually scheduled in advance)
• Your doctor explains why the treatment was medically necessary for your specific situation
• The insurance medical director explains their concerns
• They discuss clinical evidence and guidelines
• Sometimes they reach agreement on the spot; sometimes the insurance company takes time to reconsider

Success rate: Peer-to-peer reviews have a high success rate for overturning denials, especially CO-50 (not medically necessary) denials, because they allow doctors to have a professional conversation.

Important: Your provider doesn't need to request this through the appeal process—they can request it directly with your insurer. The conversation doesn't replace your appeal, but it supports it.

External review is the next step after an internal appeal is denied. An independent, external medical reviewer (not employed by your insurance company) reviews your case and makes a determination.

Why it exists: External review is a protection for patients. It prevents insurance companies from having the final say on medical necessity decisions. The external reviewer is impartial and often more willing to approve treatments that an insurer might deny.

When you're eligible:

• You've exhausted your internal appeal (it was denied)
• The denial involves a medical judgment (like "not medically necessary") rather than an administrative reason
• You have health insurance subject to the ACA, state insurance laws, or state HMO regulations
• Medicare and Medicaid beneficiaries also have external review rights

Types of external review:

• Expedited (urgent): For healthcare decisions that can't wait. Decision within 72 hours
• Standard: For non-urgent denials. Decision within 30 days

How to request:

• When your insurer denies your internal appeal, their letter should explain external review rights
• You typically have 4 months from the internal appeal denial to request external review
• Contact your state's external review organization or independent review entity (IRE)
• Provide your case information and copies of all relevant documents

Important: External review reversal rates are often higher than internal appeal reversal rates because the reviewer is independent and may not have the same financial incentives as your insurer.

The timeline depends on the type of appeal and whether you request expedited review:

Internal Appeal:

• Standard review: 30 days from submission
• Expedited review: 72 hours (if you can demonstrate the standard timeline would be harmful)

External Review:

• Expedited (urgent): 72 hours
• Standard: 30 days

Medicare Appeal:

• Level 1 (redetermination): 60 days
• Level 2 (reconsideration): 60 days
• Level 3 (Administrative Law Judge): Varies, often 2-3 months or longer

Medicaid Appeal:

• Varies by state, typically 30-90 days

Timeline tips:

• Submit your appeal as early as possible within your deadline window
• Request expedited review if your health condition requires urgent treatment
• Follow up frequently to check status
• Total time from denial to resolution can be several months, so be patient but persistent

Yes, but how many times you can appeal depends on your insurance type and the reason for appeal:

Commercial Insurance:

• You can appeal an internal denial once (first level appeal)
• If that's denied, you can request external review by an independent organization
• The external review is generally the final level for commercial insurance

Medicare:

• Multiple appeal levels: Level 1 (redetermination), Level 2 (reconsideration), Level 3 (Administrative Law Judge), Level 4 (Medicare Appeals Council), Level 5 (federal court)
• You can appeal to higher levels if denied at lower levels
• You need different documentation and justification at each level

Medicaid:

• Varies by state, but typically allows multiple appeal levels
• Check your state's Medicaid appeal procedures

When to appeal again:

• If you have new medical evidence that wasn't available before
• If you can address the specific concerns the insurer raised in their denial
• If there were procedural errors in the first appeal review
• Don't appeal again if you're just resubmitting the same argument—provide new evidence

Important: Each appeal requires you to submit within the deadline for that appeal level. Don't assume you can appeal indefinitely—pay attention to deadlines.

Here's what typically happens after you submit an appeal:

Within 5-7 business days:

• Your insurer receives and logs your appeal
• You should receive an acknowledgment (by mail or email) confirming receipt
• Your insurer assigns your case to a reviewer

Within 2-4 weeks:

• Your insurer reviews all submitted documentation
• They may request additional information from your provider or you
• If additional information is requested, respond quickly to avoid delays

Within 30 days (standard timeline):

• Your insurer makes a decision on your appeal
• You'll receive a written decision (Explanation of Appeal Determination)
• The letter will explain whether your appeal was approved, denied, or partially approved
• It will include information about external review rights if the appeal is denied

What to do while waiting:

• Keep working with your provider on the medical care if needed
• Don't assume the appeal is unsuccessful just because it takes time
• Follow up every 10-14 days if you haven't heard back and the 30-day deadline is approaching
• Document all communications with your insurer (who you spoke with, when, what they said)

If your appeal is approved: The insurer will pay the denied claim (usually within 30-45 days). The provider may write off your patient responsibility, or you may receive a refund if you already paid.

The Affordable Care Act (ACA) established several important consumer protections regarding insurance denials and appeals:

Appeal rights:

• Right to a full and fair review of any claim denial
• Right to appeal to two levels (internal and external review)
• Right to an expedited review if your condition is urgent
• Right to submit written comments, documents, and records to support your appeal

Transparency rights:

• Right to a clear explanation in non-technical language of why a claim was denied
• Right to know about appeal procedures and deadlines
• Right to request information about internal guidelines used in making decisions

Pre-authorization protections:

• If your insurer asks for pre-authorization, they must respond within specific timeframes
• If they don't respond, the care is automatically approved (deemed as authorized)

No pre-existing condition exclusions:

• Insurers cannot deny coverage or charge more based on pre-existing conditions

Coverage of preventive care:

• Certain preventive services must be covered without cost-sharing

Patient advocate assistance:

• Many insurers are required to provide patient advocate services
• You can request help from a patient advocate at no cost

The No Surprises Act (also called the Surprise Billing Protection) is a federal law that protects you from unexpected medical bills, particularly from out-of-network providers.

What it does:

• Limits your out-of-pocket costs for emergency services, even if the provider is out-of-network
• Protects you from surprise bills from out-of-network providers in emergency situations
• Requires transparency about what you'll owe before receiving services
• Establishes a dispute resolution process between insurers and providers

Key protections:

• Emergency services: You pay in-network cost-sharing for emergency services, even if the provider is out-of-network
• Air ambulance: Most air ambulance services are protected
• Post-emergency care: You cannot be balance-billed for post-emergency care that was necessary to treat your emergency condition
• In-network facility, out-of-network provider: If you go to an in-network hospital but see an out-of-network doctor, you pay in-network costs

How to use this protection:

• If you receive a surprise bill, contact the provider and explain you believe the bill violates the No Surprises Act
• Contact your state insurance commissioner with a complaint
• Appeal the bill as a denial of coverage, citing the No Surprises Act

Important: The No Surprises Act doesn't mean you have zero out-of-pocket costs—you still pay your normal copay, coinsurance, or deductible. It just limits your costs to in-network amounts.

The Mental Health Parity Act (part of the Mental Health Parity and Addiction Equity Act) requires insurance companies to treat mental health and substance use disorder benefits the same as physical health benefits.

What it means:

• Mental health and addiction treatment cannot have lower benefits than medical and surgical care
• Insurers can't impose stricter limitations (like higher copays, fewer visits, or longer waiting periods) on mental health care
• Coverage standards must be equivalent between mental health and physical health services

What it covers:

• Mental health conditions (depression, anxiety, bipolar disorder, etc.)
• Substance use disorders (alcohol and drug addiction treatment)
• Behavioral health services
• Counseling and therapy
• Psychiatric medications

If your mental health claim is denied:

• File an appeal and cite the Mental Health Parity Act
• Compare your mental health benefits to physical health benefits to show the disparity
• If the insurer is treating mental health differently, request a parity analysis
• File a complaint with your state insurance commissioner if you suspect parity violations

Important: Just because mental health treatment is covered doesn't mean everything is automatic. Insurers can still require medical necessity determinations, but they must apply the same standards they use for physical health care.

Yes. Medicare beneficiaries have strong appeal rights, with multiple levels of appeal available.

Medicare appeal levels:

• Level 1 - Redetermination: Request that Medicare review the initial decision. Submit within 120 calendar days
• Level 2 - Reconsideration: If redetermination is denied, request a second review by a different entity. Submit within 180 days
• Level 3 - Administrative Law Judge (ALJ): For amounts over $150, request a hearing before an independent ALJ. Submit within 60 days
• Level 4 - Medicare Appeals Council: Request review of the ALJ decision. Submit within 60 days
• Level 5 - Judicial Review: File in federal district court

Important Medicare details:

• You must request each appeal level within the specified timeframe
• There are higher dollar thresholds required to proceed to higher appeal levels
• You can represent yourself or have a lawyer represent you
• If you win, Medicare pays the claim and your legal fees may be eligible for reimbursement

How to appeal Medicare:

• Call 1-800-MEDICARE for assistance
• File through your Medicare online account at MyMedicare.gov
• Contact your Medicare Advantage plan directly if you're in an MA plan

Get help: Medicare provides free resources and patient advocates through State Health Insurance Assistance Programs (SHIAPs). Contact your state's SHIAP for free help with Medicare appeals.

Yes. Medicaid beneficiaries have appeal rights, though the specific process varies by state.

General Medicaid appeal process:

• You should receive a notice explaining the denial and your appeal rights
• Request an appeal within the timeframe specified (usually 30-90 days, depending on state)
• Submit your appeal in writing to your state Medicaid agency
• Your state will provide a hearing or review process

Important Medicaid facts:

• Each state has different appeal procedures, so check your state's Medicaid program
• Some states allow expedited appeals for urgent situations
• You may request a hearing before a state hearing officer
• Many states have patient advocate services available for free

How to appeal Medicaid:

• Contact your state's Medicaid agency directly (search "[Your State] Medicaid")
• Ask about patient advocate services or legal aid organizations in your state
• Contact your state's Health Insurance Assistance Program (SHIP) for help

Legal aid: Many states have legal aid organizations that provide free help with Medicaid appeals. Search "legal aid [your state]" for local resources.

A patient advocate can be invaluable in navigating insurance denials. Here's when to consider hiring one:

You should hire a patient advocate if:

• You feel overwhelmed by the appeal process
• The denied claim is for a significant amount of money (over $5,000-10,000)
• Your case is complex (multiple denials, multiple providers involved)
• You don't have time to research and prepare an appeal yourself
• Your first appeal was denied and you need to pursue external review
• Your health condition makes it difficult for you to handle this yourself
• You're dealing with a serious condition (cancer, rare disease) that requires specialized knowledge

Free resources first: Before hiring a private advocate, try these free options:

• State Health Insurance Assistance Program (SHIP) - Free help for Medicare beneficiaries
• Your insurer's patient advocate - Many insurers provide free patient advocate services
• Legal aid organizations - Free help if you qualify by income
• Nonprofit organizations related to your condition (American Cancer Society, American Heart Association, etc.)

Private patient advocates: If you hire a private advocate, expect to pay $50-150/hour, or sometimes a flat fee for appeal assistance. Some work on contingency (percentage of successful recovery).

A healthcare attorney can represent you in your appeal and provide legal advice. Here's when to consider hiring one:

You should consider an attorney if:

• The denied claim is for a very large amount (over $25,000-50,000)
• You're at the Medicare ALJ (Administrative Law Judge) level or higher
• You believe the insurance company has acted illegally or in bad faith
• You want to file a lawsuit against your insurer
• The denial affects your ability to work or your health is deteriorating
• You're pursuing an external review and want professional representation
• Your case involves contract interpretation or policy disputes

Cost considerations:

• Many attorneys work on contingency (you pay only if you win)
• Some charge hourly rates ($150-400+/hour)
• Consult a few attorneys to compare fees and find the best fit
• If you win, you may recover attorney fees from the insurer

How to find a healthcare attorney:

• Ask your state bar association for a referral
• Search "healthcare attorney [your state]" or "insurance attorney [your state]"
• Contact legal aid organizations (they may provide free or low-cost referrals)
• Ask patient advocacy groups if they have attorney recommendations

Initial consultation: Most attorneys offer free or low-cost initial consultations. Use this to assess whether you have a good case.

Filing a complaint with your state's insurance commissioner can pressure your insurer to reconsider a denial. Here's how:

Steps to file a complaint:

• 1. Find your state commissioner: Search "[Your State] insurance commissioner" or visit your state's Department of Insurance website
• 2. Gather documentation: Collect your EOB, appeal denial, policy documents, and all correspondence with your insurer
• 3. Write a complaint letter: Clearly explain what happened, why you believe it's wrong, and what you want (payment, review, etc.)
• 4. Submit: Mail, email, or submit online through your state's insurance commissioner website (most states have online complaint forms)
• 5. Follow up: Provide any additional information requested by the commissioner's office

What to include in your complaint:

• Your name, contact information, and policy number
• Insurer name and contact information
• Details of the claim (date of service, amount, provider, diagnosis)
• Denial reason and the CARC code
• Why you believe the denial is improper
• What outcome you're requesting
• Copies of all relevant documents

What the commissioner can do:

• Investigate your complaint
• Request information from your insurer
• Demand the insurer review the claim again
• Issue violations or fines if the insurer violated regulations
• Mediate between you and your insurer

Important: Filing a complaint doesn't replace your appeal, but it adds pressure and provides a check on your insurer's conduct.