How to appeal a denied health insurance claim, and how long you have
You generally have 180 days from receiving a denial to file an internal appeal with your health plan, and if the plan upholds the denial, many cases can go to an independent external review, according to HealthCare.gov. Medicare has its own multi-level appeal process with its own deadlines. You can appoint a representative to handle the appeal for you.
Deadlines by plan type
| Plan type | Internal appeal | After the internal appeal |
|---|---|---|
| Employer plan (ERISA) or Marketplace plan | Generally 180 days from the denial (HealthCare.gov) | External review by an independent reviewer where available |
| Original Medicare | Redetermination within 120 days of the initial determination (CMS) | Reconsideration, ALJ hearing, Council review, judicial review |
| Medicare Advantage | Reconsideration, typically within 60 days of the denial notice (plan rules) | Automatic independent review if the plan upholds the denial |
| Medicaid / managed Medicaid | Varies by state and plan | State fair hearing |
The steps
- Read the denial. The EOB or denial letter states the reason (a code and a sentence) and the deadline. Common reasons: not medically necessary, no prior authorization, out of network, missing information, not a covered benefit, or a coding problem on the provider's claim.
- Call the plan and the provider. Many denials are the provider's to fix: a wrong code, a missing modifier, or an authorization that was obtained but not attached. Ask the provider's billing office to correct and resubmit. Ask the plan what it needs.
- File the internal appeal in writing before the deadline. State the claim number, dates of service, and why the denial is wrong. Attach records, the doctor's letter of medical necessity, the plan's own policy language if it supports you, and proof of authorization or network status. Keep copies and send it in a way you can prove.
- Track it. Plans must decide within set timeframes (faster for urgent care). Follow up in writing.
- Request external review if the appeal fails. The denial letter must tell you how. An independent reviewer's decision is binding on the plan in most cases (HealthCare.gov).
Appointing someone to help
You can authorize another person or a service to act for you. Under the Department of Labor's benefit claims procedure rules, employer plans must recognize an authorized representative, using the plan's reasonable procedures for the authorization. Medicare lets you appoint a representative for claims and appeals with a signed form. The plan's form or letter is what makes the appointment valid; ask the plan which it needs.
What makes an appeal work
- It answers the stated denial reason directly, not the claim in general.
- It cites the plan's own coverage policy or the relevant Medicare coverage determination.
- It includes the treating physician's letter and the records that show the criteria were met.
- It is filed inside the deadline, with proof of filing.
Large single claims (an MRI, surgery, emergency visit, or out-of-network bill in the thousands) are where professional help pays for itself. The review itself is free; see insurance claim and denial assistance for patients. Small balances are usually fastest to resolve with a call to the provider's billing office.
Sources
- HealthCare.gov, Internal appeals
- HealthCare.gov, External review
- U.S. Department of Labor, Benefit claims procedure regulation FAQs
- U.S. Department of Labor, Filing a claim for your health benefits
- Medicare.gov, Claims and appeals
- CMS, Original Medicare (fee-for-service) appeals: five levels; redetermination within 120 days, reconsideration within 180 days
Figures attributed to a source are that source's; commonly used benchmarks are labeled as such. Verify deadlines against your own payer contracts.
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Related services
- For patients — Free claim reviews, then reimbursement requests and appeals for patients for a flat fee.