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Yes, a health insurer may use AI in processes that affect claims or coverage. But that does not establish that every insurer uses it, or that an algorithm independently made a particular denial. If your plan denies a claim or care request, you may have the right to challenge the decision through an internal appeal and, in eligible cases, an independent external review. The exact process depends on your plan and the notice you receive.
Can my health insurer use AI to deny my claim?
AI may be used somewhere in claims handling, prior authorization, or utilization management. That is different from proving that AI alone made a specific decision. CMS has identified oversight of Medicare Part C and Part D plans’ use of AI in prior authorization and utilization management as an agency use case, including concerns about compliance, bias, and beneficiary outcomes. This shows regulatory attention to the issue; it does not establish what a particular insurer used in your case.
The NAIC Consumer Liaison Committee’s November 2024 report recommends that insurers provide a rationale for every denial, disclose AI’s role up front, and provide meaningful human clinical oversight when AI recommends a denial. Those are recommendations in a committee report, not a binding nationwide rule. The official materials cited here do not establish a universal right to be told whether AI played a role in every individual claim decision, or a national statistic showing how often AI is used or how often AI-related appeals succeed.
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Start with the denial notice and the Explanation of Benefits (EOB). The notice should explain why the plan denied the claim or request and how to dispute the decision. Identify the service, the stated reason, the date, the appeal route, and the deadline. The reason may concern medical necessity, a benefit exclusion, network status, experimental treatment, or another issue; the response should address the reason actually given.
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1. Check your plan and coverage type
Review your plan documents and ask your employer’s HR department whether an employer-sponsored plan is self-funded or fully insured. Procedures and oversight can differ by plan type and state. Marketplace, individual, employer, and Medicare-related coverage may also follow different routes. CMS recommends checking whether an employer plan is self-funded or fully insured when determining where to seek help.
2. File an internal appeal
Follow the instructions on the notice and submit the appeal by the deadline it gives. HealthCare.gov describes a general 180-day period after the denial notice to request an internal appeal, but the notice, plan materials, and applicable rules should guide your specific case. Use the insurer’s form if required, or send a written appeal with identifying and claim details. Explain why you believe the decision is wrong and include relevant supporting information, such as a clinician’s letter or records.
3. Request relevant decision information
When useful, ask the plan for the information and criteria relevant to the denial and appeal. CMS consumer guidance describes rights to information about a denial and to see and respond to information used in an internal appeal decision. Do not assume this means you can obtain an AI model’s source code, every input used by a model, or a complete audit of how it operated.
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4. Consider external review
If the plan upholds the denial, check whether the decision is eligible for external review and follow the instructions and deadline in the final notice. An independent reviewer—not the insurer—reviews eligible cases, and the insurer must accept the reviewer’s decision under the process described by HealthCare.gov. Urgent cases may qualify for expedited review. State and federal procedures can differ.
5. Get help if you need it
CMS and HealthCare.gov direct consumers to state Consumer Assistance Programs and state insurance regulators where available. The contact information in your notice and the applicable state process can help identify the right route for your coverage.
What deadlines should I look for?
HealthCare.gov summarizes general timelines for the processes it describes. They are not a substitute for the deadline in your notice or the rules that apply to your plan and jurisdiction.
| Process or notice | General timeline described by HealthCare.gov | What to check |
|---|---|---|
| Notice of denial for prior authorization | 15 days | Whether the notice and plan rules for your request use this timeline. |
| Notice of denial for services already received | 30 days | The applicable post-service claim process. |
| Notice for an urgent-care case | 72 hours | Whether the case qualifies as urgent and whether faster handling applies. |
| Requesting an internal appeal | Generally 180 days after the denial notice | The filing deadline stated in your notice and plan materials. |
| Internal appeal decision | 30 days for pre-service appeals; 60 days for post-service appeals | Whether urgent or other plan-specific rules change the timeframe. |
| Requesting external review | HealthCare.gov describes a general four-month filing period | The final denial notice and the state or federal process that applies. |
| External review decision | Up to 45 days for standard review; 72 hours for expedited review | Whether the case is eligible and qualifies for expedited handling. |
State processes that meet federal minimum standards may govern external review; a federal process applies in certain circumstances. Because plan type and state law affect the route, treat the figures above as general guidance rather than universal deadlines.
What records should I keep for an appeal?
Keep a dated, organized record so you can show what the plan decided, what you submitted, and when you communicated with it.
- The denial notice, EOB, and relevant plan documents or summary plan description.
- Copies of appeal forms, letters, and other information you submit, including supporting medical information.
- Information the insurer sends or identifies as relevant to its decision.
- Notes of calls, including the date and time, the representative’s name and title, and what was discussed.
Keep originals and send copies where possible. Use the plan’s official appeal channel and retain a copy of each submission.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.Can I ask whether AI made the decision?
You can ask the plan whether AI or an automated system was involved and what information and criteria support the denial. The reviewed federal consumer guidance supports seeking information about the denial and information used in an internal appeal, but it does not establish a universal nationwide right to disclosure of every tool’s role in an individual decision. It also does not guarantee access to model code, all model inputs, or an AI audit through an ordinary appeal.
A useful written request is specific: identify the claim or care request, ask for the denial rationale and the records or criteria relevant to the decision, and ask whether an automated system contributed to the review. Keep the response with your appeal records.
What happens to my health information?
The available guidance does not establish a comprehensive insurer-specific rule requiring disclosure of every data item an AI model used, its internal logic, or every third party with access to claim information. Privacy rights depend on the organization, the data, and the laws that apply.
CMS’s responsible-AI guidance, last reviewed August 26, 2025, advises CMS staff not to place sensitive personally identifiable information or protected health information into publicly accessible AI tools. That is agency guidance for CMS staff, not a complete statement of private insurers’ obligations or a rule telling consumers how every insurer handles data. For an appeal, share information relevant to the claim through the insurer’s official channel, keep a copy, and ask the plan what information supports its decision.
Sources and scope
This article describes U.S. consumer guidance. Its procedural timelines reflect HealthCare.gov’s general summaries, and its discussion of AI-specific policy recommendations reflects the NAIC Consumer Liaison Committee’s November 2024 report. CMS’s responsible-AI guidance was last reviewed August 26, 2025. Rules and procedures can vary by state, plan type, and coverage; for a live denial, use the notice and current plan documents, and contact your state regulator or a qualified benefits or legal adviser for case-specific help.
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