How to appeal a health insurance denial

Appeal deadlines and decision times

Step 1: File an internal appeal

1. Read the denial notice closely. Note the reason, the claim number, the plan rule it cites and the appeal deadline.
2. Call the insurer to confirm the reason and ask for a copy of your claim file and the medical policy used. Write down the date, the name of the person and what they said.
3. Get your clinician involved. Ask for a letter of medical necessity and the relevant records. Your clinician can also file the appeal for you if you give written permission.
4. Fill out the insurer's appeal form or write a letter (outline below). Send copies, keep your originals, and use a method you can track.
5. Ask for an expedited appeal if waiting could seriously harm your health.

For employer plans covered by federal rules, a different person from the one who made the first decision must review the appeal, and plans generally can't charge fees to file a claim or appeal.

What to put in an appeal letter

• Your name, member ID, claim or reference number, and the date of service or request.
• One sentence on what was denied and that you are requesting an internal appeal.
• Why the care is medically necessary, in plain words, with your clinician's letter attached.
• The specific plan language or medical guideline that supports you, if you have it.
• If the denial was a coding or paperwork error, the corrected information.
• A list of attachments and a request for a written decision by the required deadline.

Step 2: Ask for an external review

If the insurer still says no, file a written request for external review within 4 months of the final notice. An independent reviewer decides, and your insurer is required by law to accept that decision. Under the HHS-run process there's no charge; other processes can charge no more than $25.

• What qualifies: denials that involve medical judgment, denials saying a treatment is experimental or investigational, and cancellation of coverage over claimed false or incomplete application information.
• Who runs it: your state, if its process meets federal standards; otherwise HHS. Your denial notice tells you which applies and how to file.

Don't delay urgent or emergency care while you appeal. If you have chest pain, trouble breathing, signs of stroke or another emergency, call 911. Emergency care doesn't need prior approval.

If you lose the appeal

Ask the provider for a self-pay price or a payment plan, and look at how to negotiate a medical bill. Your state insurance department can answer questions about your rights. Gabriel Plus has member prices close to cost on lab tests, supplements, prescriptions and bioregulators. Gabriel is a membership, not health insurance.