lamdis

How to appeal a health insurance denial

Reviewed · 13 sources

The short answer

Read the denial closely, find your deadline, get your claim file and the plan’s criteria, ask your doctor for a letter, and send a short, factual appeal before the deadline. If the plan says no again, there is usually another level, often an independent reviewer.

Step by step

  1. Read the denial closely

    Find four things: exactly what was denied (the service or drug, the date and the claim or reference number), the reason in the plan’s own words, the deadline to appeal, and where to send the appeal. Compare it with the Explanation of Benefits if you have one.

    If the problem looks like paperwork, such as a wrong code or member number, call your provider’s billing office first; a corrected claim can be faster than an appeal. See billing and coding errors.

  2. Find your plan type and your deadline

    The rules depend on where your coverage comes from. The table below gives the federal deadline for each kind of plan; if your letter prints an earlier date, go by the earlier one.

  3. Get your file and the rules they used

    With a job-based or Marketplace plan you can ask, free of charge, for copies of everything relevant to your claim (29 CFR 2560.503-1(h)(2)(iii)), and for any internal guideline the plan relied on ((g)(1)(v)(A)). Medicare Advantage plans must make their internal coverage criteria publicly accessible (42 CFR 422.101(b)(6)). Knowing the exact criteria tells you what your appeal has to show.

  4. Ask your doctor for a letter

    For denials about medical need, a letter of medical necessity from the treating doctor often carries the most weight. A useful letter names the diagnosis, the treatments already tried and how they went, why this treatment is needed now, what is likely to happen without it, and how the patient meets the plan’s own criteria.

  5. Write a short, factual appeal

    Name the claim number and say plainly that you are appealing. Take the plan’s stated reason and answer it point by point, using your records. Keep every factual statement tied to a document you are sending, and list the enclosures at the end.

  6. Send it and keep proof

    Use the method the denial letter gives: mail, fax or the plan’s online portal. Keep a copy, and keep proof of the date: a fax confirmation, a portal receipt or tracked mail. The plan’s decision clock starts when it receives your appeal.

  7. Ask for a fast decision if waiting could harm you

    Most plans have a fast track for urgent cases. Employer and Marketplace plans must decide urgent appeals within 72 hours (29 CFR 2560.503-1(i)(2)(i)), as must Medicare Advantage plans (42 CFR 422.590(e)(1)), Part D plans (42 CFR 423.590(d)(1)) and Medicaid plans (42 CFR 438.408(b)(3)). A note from your doctor saying that waiting could seriously harm your health helps.

  8. If the answer is still no, go outside the plan

    There is usually another level. For job-based and Marketplace plans it is often an independent external review, and the insurer must accept the reviewer’s decision (HealthCare.gov). Medicare cases go to an independent review entity and then to hearings, Medicaid cases to a state fair hearing, federal employee plans to OPM, and TRICARE cases to a formal review. Your plan’s guide explains the next level.

Deadlines by plan type

The deadline to file the first appeal, from the federal rule for each kind of plan. Each guide shows the decision times and the next level.

Employer plan

180 days from notice_received

Insurance through your job or a family member’s job, including COBRA.

Marketplace plan

180 days from notice_received

A plan you bought yourself through HealthCare.gov or your state’s marketplace.

Medicare Advantage

60 days from notice_received

A private Medicare plan (Part C), often from UnitedHealthcare, Humana, Aetna and others.

Medicare Part D

60 days from notice_received

Prescription drug coverage under Medicare, alone or inside a Medicare Advantage plan.

Original Medicare

120 days from notice_received

Medicare Part A and Part B, billed directly to Medicare, often with a Medigap policy.

Medicaid

60 days from notice_date

Medicaid, including Medicaid health plans run by private companies, and CHIP.

FEHB (federal employees)

6 months from notice_date

The Federal Employees Health Benefits Program for federal workers and retirees.

TRICARE

90 days from notice_date

Health coverage for active-duty service members, retirees and their families.

Is it worth appealing?

Very few people appeal. Insurers selling plans on HealthCare.gov denied 19% of in-network claims in 2024, and fewer than 1% of denied claims were appealed (KFF). In a 2023 KFF survey, 69% of insured adults with a denied claim did not know they had a right to appeal (KFF).

Results vary a great deal by plan and by reason. Medicare Advantage insurers fully or partly overturned 80.7% of the prior-authorization denials that were appealed in 2024, though only 11.5% were appealed (KFF). Marketplace insurers, by contrast, upheld 66% of the internal appeals they decided in 2024 (KFF). A clear look at why you were denied is the best guide to whether your own appeal is worth the effort.

Guides by denial reason

Guides for drugs and treatments

External review by state

State rules mostly matter for individual and Marketplace plans and for job-based plans bought from an insurer.

Questions people ask

Can I appeal a health insurance denial?

Yes. Job-based plans, Marketplace plans, Medicare, Medicaid, the federal employee program and TRICARE all have a formal appeal process with written deadlines. The guides above link to each rule.

How long does the plan have to decide?

It depends on the plan and on whether you have had the care yet. A job-based or Marketplace plan with one level of appeal has 30 days for care you haven’t had and 60 days for care you already received (29 CFR 2560.503-1(i)(2)). A Medicare drug plan has 7 days for a drug you haven’t received (42 CFR 423.590(a)(1)). Urgent appeals are decided within 72 hours.

Do I need a lawyer?

No rule requires one, and you, a representative or your doctor can file. Free help exists: many states run Consumer Assistance Programs for insurance problems (CMS), and people with Medicare can get free counseling from their State Health Insurance Assistance Program (Medicare.gov).

What if I missed the deadline?

Ask anyway, in writing, and explain why you were late. Medicare accepts late appeals for good cause, such as illness (Medicare.gov), and the federal employee program can extend its time limit when something outside your control got in the way (5 CFR 890.105(b)(1)).

What is external review?

An independent organization looks at your case after the plan’s own appeal. For job-based and Marketplace plans the insurer is required by law to accept its decision (HealthCare.gov).

Sources

  1. eCFR: 29 CFR 2560.503-1, Claims procedureProvide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination
  2. eCFR: 45 CFR 147.136, Internal claims and appeals and external review processesa health insurance issuer offering individual health insurance coverage must provide for only one level of internal appeal before issuing a final determination
  3. HealthCare.gov: Internal appealsYou must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.
  4. HealthCare.gov: External reviewYour insurer is required by law to accept the external reviewer’s decision.
  5. eCFR: 42 CFR 422.101, Requirements relating to basic benefitsMA organizations may create publicly accessible internal coverage criteria that are based on current evidence in widely used treatment guidelines or clinical literature when coverage criteria are not fully established in applicable Medicare statutes, regulations, NCDs or LCDs.
  6. eCFR: 42 CFR 422.590, Timeframes and responsibility for reconsiderationsno later than 72 hours after receiving the request
  7. eCFR: 42 CFR 438.408, Resolution and notification: Grievances and appealsThe enrollee must have no less than 90 calendar days and no more than 120 calendar days from the date of the MCO's, PIHP's, or PAHP's notice of resolution to request a State fair hearing.
  8. Medicare.gov: Filing an appealSHIPs are state programs that get money from the federal government to give free local health insurance counseling to people with Medicare.
  9. Medicare.gov: Appeals in Original MedicareYou must file your appeal by the date in the MSN.
  10. CMS: Consumer Assistance ProgramMany states offer help to consumers with health insurance problems through Consumer Assistance Programs
  11. KFF: Claims Denials and Appeals in ACA Marketplace Plans in 2024Consumers rarely appeal denied claims (fewer than 1% of denied claims were appealed), and when they do, insurers usually uphold their original decision (66% of appeals were upheld).
  12. KFF: Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024most appeals (80.7%) were partially or fully overturned in 2024
  13. KFF: Consumer Survey Highlights Problems with Denied Health Insurance ClaimsMost consumers with denied claims (69%) do not know that they have appeal rights

This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.

Guides by plan