Health Insurance Denial

The 10-step appeal workflow

1. 1

   Get the denial reason in writing — the Explanation of Benefits (EOB)

   The EOB or denial letter must state the specific reason for denial and reference the policy provision or clinical guideline supporting it. If you received the denial by phone, request a written EOB immediately. The denial reason determines which appeal path applies: medical necessity, prior authorization, out-of-network, coding error, etc.

2. 2

   Confirm whether the plan is ACA-compliant and your appeal rights

   ACA-compliant plans (individual marketplace, most employer plans subject to ACA) provide federally guaranteed appeal rights: at least one level of internal appeal and access to external (Independent Review Organization, IRO) review. Self-funded employer plans subject to ERISA have similar but somewhat different rules. Short-term limited-duration plans, faith-based health sharing ministries, and some other plans don't have ACA appeal protections.

3. 3

   Calendar the 180-day internal appeal deadline

   Under ACA-compliant plans, you have at least 180 days from the date of denial to file an internal appeal. Standard internal appeals must be decided within 30 days for pre-service requests, 60 days for post-service. Expedited appeals (urgent care situations) must be decided within 72 hours. Missing the 180-day deadline forfeits your appeal rights.

4. 4

   Gather supporting evidence — especially clinical documentation

   For medical-necessity denials, the most valuable evidence is your treating physician's letter of medical necessity (LMN) explaining why the treatment is appropriate for your specific condition. Add: peer-reviewed clinical literature supporting the treatment; clinical practice guidelines from medical societies; documentation of prior treatments tried and failed; the specific diagnoses involved (ICD-10 codes); and the procedure codes (CPT) being denied.

5. 5

   Submit the internal appeal in writing

   Most insurers have a specific appeals address or portal. The appeal should: state explicitly that it's an appeal (not a request for reconsideration); identify the claim/service being appealed; respond to the specific denial reason; cite the supporting evidence; and request specific relief (full coverage of the service). Keep copies of everything. Track the appeal via certified mail or insurer portal confirmation.

6. 6

   Request an expedited appeal if care is urgent or denied for an active treatment

   Expedited appeals must be decided within 72 hours under ACA rules. Your treating physician can certify the situation as urgent. Don't accept a standard timeline for urgent care — explicitly request expedited review.

7. 7

   If internal appeal is denied, request external (IRO) review

   After exhausting internal appeals, ACA-compliant plans must offer external review by an Independent Review Organization — a panel of physicians independent of the insurer. External review is typically free to the policyholder; the insurer pays. External review must be requested within 4 months of the final internal denial. The IRO decision is binding on the insurer (they must follow it) but you can pursue further action if denied.

8. 8

   Check whether the No Surprises Act applies (out-of-network billing)

   The federal No Surprises Act (effective 2022) protects patients from surprise out-of-network bills in emergency situations and from out-of-network ancillary providers (anesthesiologists, radiologists, etc.) at in-network facilities. If you received an out-of-network bill in these situations, you may be protected — the insurer and provider negotiate through an independent dispute resolution process, not by billing you. CMS has a complaint process for No Surprises Act violations.

9. 9

   File a complaint with your state Department of Insurance

   After exhausting insurer appeals, file a written complaint with your state DOI. DOIs investigate whether the insurer followed regulatory requirements (timeliness, communication, evidence consideration). Many disputes resolve in the complaint stage. For ERISA self-funded plans, the Department of Labor (EBSA) is the federal regulator.

10. 10

    Consider professional escalation if claim is large or denial appears unreasonable

    A policyholder-side attorney specializing in health insurance can pursue litigation for unreasonable denials, especially for high-dollar claims (organ transplants, oncology, complex surgeries). Some attorneys take cases on contingency. State unfair claim settlement practices laws and ERISA fiduciary duty rules provide additional remedies in some situations.

Related

FAQ

How long do I have to appeal a health insurance denial?

Under ACA-compliant plans (most individual marketplace plans and most employer plans), you have at least 180 days from the date of denial to file an internal appeal. After exhausting internal appeals, you have 4 months to request external (IRO) review. Non-ACA-compliant plans (short-term, ministry plans) may have shorter deadlines or no guaranteed appeal rights — read the policy or EOB for the specific deadline.

What's the difference between an internal appeal and external review?

Internal appeal is conducted by the insurer itself (or an internal reviewer). External review is conducted by an Independent Review Organization (IRO) — a panel of physicians not employed by or paid by the insurer. External review is required for ACA-compliant plans after internal appeals are exhausted, and the IRO's decision is binding on the insurer. External review is typically more independent and reverses denials more often than internal appeals.

Does my doctor need to write something for my appeal?

Strongly recommended. A letter of medical necessity (LMN) from your treating physician is often the single most important piece of evidence for medical-necessity denials. The LMN should explain: your specific diagnosis; why this treatment is appropriate for your condition; what alternatives have been tried; and why the denied treatment is the best clinical option. Generic appeal letters without physician support have much lower success rates.

What is the No Surprises Act and when does it apply?

The federal No Surprises Act (effective January 2022) protects patients from surprise out-of-network bills in three situations: (1) emergency services at any hospital; (2) out-of-network ancillary services at an in-network facility (anesthesia, radiology, pathology, neonatology, etc.); (3) air ambulance services. In these cases, the patient pays only the in-network cost-sharing amount, and the insurer and out-of-network provider negotiate the rest through an independent dispute resolution (IDR) process. If you received a surprise bill that violates the Act, contact your insurer first and CMS at 1-800-985-3059 to file a complaint.

Can my insurer deny a treatment my doctor says I need?

Yes — insurers regularly deny treatments their medical reviewers consider not medically necessary even when a treating physician recommends them. The dispute centers on the insurer's medical-necessity criteria vs the physician's clinical judgment. The appeal process (internal then external IRO review) is the formal mechanism for resolving these disputes. External IRO reviewers — independent physicians with relevant specialty expertise — overturn a significant portion of medical-necessity denials. Don't accept the initial denial as final, especially for serious or expensive treatments.