How to Appeal an Insurance Denial (And Win)
Learn how to appeal health insurance claim denials. Over 50% of appeals are successful. Our step-by-step guide covers internal appeals, external reviews, and what to say.
Insurance Denials Can Be Overturned
If your health insurance denied a claim, don't give up. Studies show that 50-60% of appealed denials are overturned in the patient's favor. Insurance companies count on most people not appealing—but you have the legal right to challenge any denial. This guide walks you through the appeals process step by step.
Common Reasons for Claim Denials
Understanding why your claim was denied is the first step to a successful appeal. The denial reason determines your appeal strategy.
- Not medically necessary: Insurance doesn't agree the treatment was needed
- Prior authorization not obtained: Required approval wasn't secured beforehand
- Out-of-network provider: Provider isn't in your plan's network
- Service not covered: Treatment excluded from your plan benefits
- Coding errors: Wrong diagnosis or procedure codes submitted
- Experimental/investigational: Insurance considers treatment unproven
- Duplicate claim: Service appears to have been billed twice
- Timely filing: Claim submitted after deadline (usually appealable)
Your Appeal Rights
Under the Affordable Care Act, you have the right to appeal any denial. Insurance companies must provide a clear explanation of why your claim was denied and instructions for appealing. You're entitled to at least one internal appeal (reviewed by the insurance company) and, if that fails, an external review by an independent third party. Time limits apply—typically 180 days for internal appeals.
The Internal Appeal Process
Start with an internal appeal to your insurance company. This is reviewed by someone who wasn't involved in the original denial. Request your complete claim file, including the medical policies used to deny your claim. Submit a written appeal letter with supporting documentation from your doctor explaining why the treatment is medically necessary.
- Request the denial in writing with specific reasons
- Get your full claim file and medical policy criteria
- Have your doctor write a letter of medical necessity
- Include relevant medical records and test results
- Cite medical guidelines supporting your treatment
- Submit within the deadline (usually 180 days)
External Review: Your Final Option
If internal appeals fail, you can request an external review. An independent review organization (IRO) not affiliated with your insurance company evaluates your case. External reviewers overturn denials about 40% of the time. The decision is binding on the insurance company. For urgent cases, you can request expedited external review (decision within 72 hours).
Writing an Effective Appeal Letter
Your appeal letter should be clear, factual, and professional. Include your name, policy number, claim number, and date of service. State that you're appealing the denial and reference the specific reason given. Explain why the treatment is medically necessary, citing your doctor's opinion and medical guidelines. Attach supporting documentation and request a written response.
How to Appeal a Health Insurance Denial
Get the denial in writing
Request a written denial letter explaining the specific reason for denial and the medical policy criteria used. This is required by law and tells you exactly what to address in your appeal.
Review your policy and the denial reason
Read your plan's Summary of Benefits and the specific exclusion or policy cited. Understand exactly what criteria weren't met so you can directly address it.
Gather supporting documentation
Collect medical records, test results, and physician notes supporting medical necessity. Ask your doctor to write a letter explaining why the treatment is necessary for your specific condition.
Write and submit your internal appeal
Draft a clear appeal letter addressing each denial reason. Include all supporting documentation. Submit before the deadline (usually 180 days) via certified mail or the method specified by your insurer.
Request external review if needed
If internal appeal is denied, request external review within 60 days (4 months in some states). An independent organization will review your case, and their decision is binding on the insurer.
Frequently Asked Questions
How often are insurance appeals successful?
Internal appeals are successful about 50-60% of the time. External reviews overturn denials approximately 40% of the time. Overall, patients who appeal have a good chance of getting their denial reversed.
How long do I have to appeal an insurance denial?
Most plans allow 180 days (6 months) to file an internal appeal from the date of the denial letter. External review requests typically must be filed within 60 days of the final internal appeal denial. Check your denial letter for specific deadlines.
Can I appeal if my claim was denied for not being medically necessary?
Yes, and these appeals are often successful. Have your doctor provide detailed documentation explaining why the treatment is medically necessary for your specific condition, citing peer-reviewed studies or established medical guidelines.
What is an external review?
External review is an independent evaluation of your denied claim by a third-party organization not affiliated with your insurance company. It's available after internal appeals are exhausted. The decision is legally binding on the insurer.
Should I get a lawyer for my insurance appeal?
Most appeals don't require a lawyer. However, for complex cases, large amounts, or repeated denials, consulting a health insurance attorney or patient advocate can help. Many offer free consultations.
What if my appeal is denied?
If internal appeals fail, request external review. If external review is also denied, you may have options through your state insurance commissioner, state attorney general, or small claims court depending on the circumstances.
Insurance Claim Denied?
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