Health insurers deny claims for many reasons, including medical necessity and coding errors. You have the right to appeal and often to an independent external review.
Steps to appeal
- Read the explanation of benefits and denial letter for the reason and appeal deadline.
- Ask your provider to check for billing errors and to support your appeal.
- File an internal appeal in writing, including medical records and a letter of support.
- Keep copies and track dates.
- If denied again, request an external review by an independent organization.
Your rights
- Most plans must provide an internal appeal and external review under federal rules.
- Urgent cases can be expedited.
- You can ask for the claim file.
- State insurance departments help with complaints.
Strengthen your appeal
- Cite the plan's own coverage rules.
- Provide peer-reviewed guidelines where relevant.
- Include a doctor's statement of medical necessity.
- Be clear and concise.
Other options
Consider a patient advocate, state consumer assistance program or an attorney in serious cases. Employer plans may be governed by federal law, with different rules from state-regulated plans.
Frequently asked questions
How long do I have to appeal?
Often 180 days, but check your plan.
Does the insurer decide the external review?
No. An independent reviewer decides.