Your claim was denied. You have rights. Here’s the exact sequence of moves — with deadlines — to fight it.
First: Read your denial letter carefully. It must state the specific reason for denial and cite the exact plan provision or clinical criteria used. Keep this letter — you will reference it in every step of your appeal.
Internal appeal — file within 180 days of denial
Submit a written appeal to your insurer. Include: denial letter, EOB, medical records, and a letter of medical necessity from your provider that directly addresses the insurer’s stated denial criteria. Request your complete claim file — the insurer must provide all documents used to deny you.
Deadlines: Decision within 30 days (pre-service) or 60 days (post-service). Urgent appeals: 72 hours.
External independent review — if internal appeal fails
Request an External Independent Review (IRO). The reviewer is assigned by your state — not your insurer. Their decision is binding: if they overturn the denial, the insurer must pay. File within 4 months of the final internal denial.
Deadline: 45 days for standard review; 72 hours for urgent/expedited.
If the external review is still denied — escalate
File a complaint with your state insurance commissioner. For employer-sponsored plans, contact the U.S. Department of Labor (DOL). For marketplace plans, contact CMS. These agencies can investigate and compel corrective action.
A Denied Claim Is Not Final
When your health insurance company denies a claim, it can feel like the final word — but it is not. The ACA guarantees you the right to appeal any coverage denial, and a significant percentage of internal appeals are overturned. Even if the internal appeal fails, you have the right to an external independent review that the insurer cannot override. Understanding the appeal process is one of the most important skills for managing your health insurance.
Why Claims Are Denied
Common denial reasons include:
- Lack of prior authorization: A service required pre-approval that was not obtained
- Not medically necessary: The insurer determined the service was not medically necessary under its clinical criteria
- Out-of-network provider: The provider is not in-network on your plan type (especially for HMO/EPO plans)
- Benefit exclusion: The service is specifically excluded from your plan
- Coding error: The provider used an incorrect diagnosis or procedure code
- Coordination of benefits: The insurer believes another plan should pay first
- Experimental treatment: The service was classified as investigational or experimental
Read the denial letter carefully — it must state the specific reason for denial, cite the plan provision or clinical criteria used, and explain your appeal rights.
Step 1: Internal Appeal
Your first step is an internal appeal filed directly with your insurer. ACA rules require insurers to:
- Accept your appeal within 180 days of receiving the denial notice (check your plan for its specific deadline — it may be shorter)
- Complete the review within 30 days for pre-service appeals (before care occurs) or 60 days for post-service appeals (after care was received)
- Complete urgent care appeals within 72 hours
- Have the appeal reviewed by someone different from the original denial decision-maker
- Provide you with all documents used to make the denial decision upon request
Build your appeal file: Gather your denial letter, Explanation of Benefits (EOB), medical records supporting the necessity of the service, your provider's letter of medical necessity, relevant clinical guidelines, and any prior authorization documentation. A strong appeal cites the insurer's own clinical criteria and demonstrates why the service meets those criteria.
Step 2: External Independent Review
If your internal appeal is denied (or if the plan upholds the denial), you have the right to request an External Independent Review (IRO — Independent Review Organization). Under the ACA:
- The external reviewer is selected by your state insurance department or an independent body — not by your insurer
- The reviewer's decision is binding on the insurer (they must comply if the reviewer overturns the denial)
- External review must be completed within 45 days (or 72 hours for urgent situations)
- You can request expedited external review when a delay would jeopardize your health
To request external review, file a request with your insurer or directly with your state insurance commissioner within 4 months of receiving the final internal appeal denial.
Expedited Appeals for Urgent Situations
If the normal appeal timeline would seriously jeopardize your life or health, you can request an expedited appeal. Insurers must complete expedited internal appeals within 72 hours. Expedited external reviews must be completed within 72 hours as well. This is the appropriate path when you need an urgent procedure or medication and are waiting for coverage approval.
Tips for a Successful Appeal
- Request your claim file. The insurer must provide all documents, records, and guidelines used in making the denial. Review them to identify weaknesses in their rationale.
- Get a detailed letter of medical necessity from your provider. This should specifically address the insurer's stated denial criteria and explain why the service is clinically appropriate.
- Cite clinical guidelines. Reference relevant medical society guidelines (AHA, ASCO, ACOG, etc.) that support the appropriateness of the service.
- Meet all deadlines. Missing the appeal filing deadline can forfeit your rights.
- Document everything. Keep copies of all correspondence, record dates of phone calls and representative names.
Need help navigating a denied claim? Call (713) 575-9904 — a licensed advisor can help you understand your options and identify whether a different plan might reduce future denials.