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To appeal a U.S. health insurance denial, identify the insurer’s specific reason, match it against your plan’s terms, and submit a focused internal appeal with supporting documents before the deadline in your denial notice. If the internal appeal fails and the denial qualifies, you may be able to ask for an independent external review. Deadlines and routes vary by plan type and state, so follow the instructions for your specific coverage.
Start with the denial notice and explanation of benefits
Read the denial notice and the explanation of benefits (EOB) together. The notice should explain why the insurer denied the claim and how to appeal. Find the exact service or amount at issue, the appeal address or online portal, any required forms, and the filing deadline. Do not assume a general deadline overrides a shorter or otherwise applicable deadline in your notice or plan documents.
Check which part of the claim was denied and the reason given. Common issues include whether a service is covered, whether it was provided in network, whether it was medically necessary, or whether the insurer considers it experimental or investigational. An appeal is strongest when it responds to the reason the insurer actually gave—not when it makes a general request to reconsider.
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Compare the denial with your plan terms
Review the relevant section of your policy or plan documents and compare it with the denial explanation. Identify the plan language that supports your position, if applicable, and explain why the insurer’s decision does not fit those terms or the facts of your claim. If the issue concerns eligibility, an uncovered service, or rescission of coverage, address that specific issue rather than treating it as a medical-necessity dispute.
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Gather documents that answer the stated reason
Make a concise packet. Depending on the denial, it may include:
- The denial notice and EOB.
- The relevant plan language.
- Claim details, such as the date of service and the provider’s name.
- Relevant medical records and clinical information.
- A short factual explanation of why the plan should reconsider.
For a medical-necessity denial, ask the treating clinician for a letter explaining why the care was medically necessary and include relevant clinical support. A provider’s rationale and supporting records can address a clinical judgment more directly than an unsupported assertion.
Write clearly and label the enclosures
Use short, factual statements and connect each point to the denial reason. The National Association of Insurance Commissioners’ consumer guide advises keeping statements brief and factual and listing the enclosures. Label documents or pages so the reviewer can locate the evidence behind each point.
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HealthCare.gov says you may use the plan’s appeal form or write a letter that includes your name, claim number, and health insurance ID number. Include any additional information you want considered. Keep the originals and submit copies unless the plan specifically requires an original request or authorization. See the NAIC guide and sample appeal letter.
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Submit the appeal and keep a record
- Use the route in your notice. Submit the appeal through the specified portal or address, and include any forms the plan requires.
- Keep a complete copy. Save the appeal, attachments, denial notice, EOB, and any confirmation or proof of delivery.
- Log conversations. Record the date and time of each call, the representative’s name and title, what was discussed, and any promised response date.
- Track the decision deadline. Note when the plan says it expects to respond and follow up if that date passes.
HealthCare.gov’s internal appeals guidance describes the general submission process, evidence, recordkeeping, and decision timing.
Know the general deadlines—and verify your plan’s
These are general U.S. timelines, not a guarantee that every state or plan uses the same rules. Check the denial notice and plan documents, and ask the plan or state regulator which process applies to your policy.
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| Stage | General timing | Important qualification |
|---|---|---|
| File an internal appeal | Generally 180 days (six months) from receiving the denial notice, according to HealthCare.gov. | Follow the deadline in the notice and plan documents if it differs or applies a more specific rule. |
| Insurer decides an internal appeal | Generally 30 days for care not yet received and 60 days for care already received, according to HealthCare.gov. | Urgent cases have expedited handling; see the notice and contact the plan promptly. |
| Request external review | HealthCare.gov gives four months from receiving the notice or final determination as general guidance. CMS lists four months for the HHS-administered federal process. | The state or plan process may differ. Use the instructions in the final denial notice. |
| External review decision | Generally within 45 days for a standard review; within 72 hours or less for an expedited review, according to HealthCare.gov and CMS. | Timing for an expedited review depends on the urgency and applicable process. |
HealthCare.gov’s external review guidance and CMS’s HHS-administered federal external review page describe these timelines. CMS’s page was last modified September 10, 2024. These are procedural time limits, not evidence of an appeal’s likelihood of success.
Ask for expedited review when waiting could be harmful
If a delay could seriously jeopardize your life or health, or your ability to regain maximum function, contact the plan and your clinician promptly. Ask whether you qualify for expedited internal review and whether an external review can be requested at the same time under the applicable rules. Explain the urgency explicitly and ask the clinician to provide supporting information.
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HealthCare.gov says an urgent internal appeal’s final decision must be made as quickly as the medical condition requires and at least within four business days; if the plan first gives the decision verbally, it must send written notice within 48 hours. For the HHS-administered federal external-review process, CMS lists a 72-hour limit for expedited decisions. Your plan’s notice and applicable process govern how to request urgent handling.
Request an external review if the denial qualifies
An internal appeal asks the insurer to reconsider its own decision. An external review asks an independent reviewer to evaluate an eligible denial. Qualifying cases can include denials involving medical judgment, experimental or investigational treatment, and certain rescissions of coverage. The final denial notice should explain how to request review and identify the applicable contact.
If the independent reviewer overturns the denial, the plan must accept that determination under the applicable process. Eligibility, steps, and deadlines can depend on whether state or federal rules govern your coverage. The CMS overview of the federal external appeals process describes the HHS-administered route.
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A state Consumer Assistance Program or Department of Insurance may help you understand an internal appeal or external review. Ask the plan or state regulator whether the rules described here apply to your policy. Some employer plans may require additional internal appeal steps. Medicare and Medicaid use different appeal routes, so this general commercial-plan guidance is not a substitute for their program-specific instructions. CMS explains these distinctions in Appealing Health Plan Decisions.
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