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If your health insurer denies a claim, appeal the denial using the reason and instructions in the written notice—whether or not an automated or AI tool was involved. Note the deadline, ask the insurer to explain the coverage or clinical basis, and submit patient-specific evidence with your internal appeal. If waiting could seriously harm the patient, ask about expedited review. The rules and deadlines can depend on your plan, state, and type of denial, so follow the notice and confirm the applicable process.
Start with the denial notice, not assumptions about AI
Save the denial letter and Explanation of Benefits (EOB). Record the service or treatment, claim number, denial date, stated reason, appeal deadline, and the address, portal, or other filing method. The notice should explain why the claim was denied and how to dispute the decision. If it is vague, ask the insurer to clarify the reason and identify the coverage provision or clinical criteria it applied. HealthCare.gov says, “You can ask your insurance company to conduct a full and fair review of its decision.” HealthCare.gov: How to appeal an insurance company decision.
Identify whether the denial concerns a service already received or a request for prior authorization or other care not yet received. That distinction can affect review timing. Also note whether the stated reason is medical necessity, a coverage exclusion, missing information, or another administrative issue; answer the reason actually given rather than arguing only that the insurer used software.
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You can ask whether an automated tool contributed to the decision and whether a qualified person can review the patient-specific record. These are practical questions, not a guaranteed right to model details or a particular form of human review. A software-assisted decision is not, by itself, proof that a denial is unlawful or wrong. Your reliable starting point is the stated basis for the denial and the plan’s appeal process.
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Build an appeal around the denial reason
Ask the treating clinician to address the reason in the notice, explain the patient’s circumstances, and describe why the requested or provided care is medically necessary when that is relevant. Include pertinent records or other documentation that answers the insurer’s stated concern. For an administrative denial, provide the information or clarification that addresses that issue instead of relying on clinical evidence alone.
In the appeal, identify the member and claim, say what decision you are challenging, explain why you believe it is incorrect, and state what outcome you are requesting. Follow the plan’s submission instructions. Send copies rather than irreplaceable originals, keep a complete copy of what you submit, and retain proof of delivery or portal submission along with notes of calls and dates.
File the internal appeal before its deadline
HealthCare.gov’s general guidance gives consumers 180 days from receiving the denial notice to file an internal appeal. Treat the deadline on your notice and the terms governing your plan as essential: the applicable process can vary. Do not let informal calls or requests for explanation run down the written appeal deadline. HealthCare.gov describes internal appeal decision periods of 30 days for care not yet received and 60 days for care already received; urgent cases can follow different timelines. Confirm which period applies to your request and plan. HealthCare.gov: Internal appeals.
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Request independent external review if eligible
If the internal appeal ends in a denial, check the final notice or EOB for external-review eligibility, instructions, administrator, and deadline. HealthCare.gov describes a general four-month window to request external review after receiving the denial notice or final determination. State processes can differ or offer additional protections, and not every denial necessarily qualifies. For the federal process administered by HHS, review scope and administration are described by CMS: HHS-Administered Federal External Review Process for Health Insurance Coverage.
HealthCare.gov describes standard external review decisions as due no later than 45 days and expedited decisions as due no later than 72 hours. Those are general process timelines, not a promise about every plan or case; verify the applicable route and timing with the notice or review administrator. Under the process described by HealthCare.gov, an independent reviewer’s decision is binding on the insurer. HealthCare.gov: External Review.
Get help with the process
- State assistance: A state Consumer Assistance Program or Department of Insurance may help you understand appeal rights and navigate the process. Available help and the regulator responsible can depend on the coverage.
- Job-based coverage: Contact the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) for help with an employer health plan.
HealthCare.gov provides information on these consumer-help channels: How can I get consumer help if I have insurance? Whether a plan is state-regulated fully insured coverage or an employer-sponsored self-funded plan can affect which rules and assistance route apply.
What AI involvement does—and does not—change
The NAIC describes insurers’ use of AI and its 2023 Model Bulletin on the use of AI systems by insurers. A 2024 report by NAIC Consumer Representatives recommends that patients and providers receive a rationale for every denial and that human clinical accountability apply to AI-recommended denials. The report says: “Patients and providers need to be given a rationale for every denial, so that they can determine whether or not to appeal the decision or resubmit the request with modifications.” That is a recommendation, not a universal individual legal right established by the sources here. NAIC: Insurance Topics—Artificial Intelligence; NAIC Consumer Representatives: Consumer Rep Report on AI & Health Insurance, November 19, 2024.
The general appeal protections described by HealthCare.gov apply to health plan decisions; the reviewed guidance does not establish a separate appeal right or a right to an AI explanation solely because AI was involved. Do not wait to prove that AI caused the denial before appealing. Focus on the plan terms, the facts in the record, the medical evidence where relevant, and the applicable review instructions.
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