Advertising & Editorial Disclosure
Insurers deny claims due to out-of-network care, incomplete paperwork or coverage disputes. You're left with unexpected bills for care you thought was covered.
Fight denied claims through appeals. Identify why the claim was rejected, collect supporting documents and file internal and external reviews to challenge the decision.
Review the Explanation of Benefits (EOB) or denial letter to know why your claim was denied. Terms like "medically necessary" or "out-of-network" are key clues.
Gather documents like the EOB, original claim, medical bills and supporting medical records before starting an appeal to ensure all bases are covered.
File an internal appeal within the insurer’s deadline, between 30 and 180 days, and provide any missing information or documentation that could support your case.
If an internal appeal doesn’t overturn the denial, file an external review with a third party or seek help from a patient advocate to bolster your case.
To appeal a denied health insurance claim, identify the reason for the denial, gather the necessary documents, file an internal appeal and pursue an external review, if needed. These steps will help build a strong appeal and improve the likelihood of overturning the denial.
Appealing a denied claim starts with knowing the reason behind the denial. Review the Explanation of Benefits (EOB) or denial letter from your insurer, paying attention to terms like "medically necessary" or "out-of-network," which help identify why the claim was rejected. This clarity guides you in gathering the right information and taking the steps to challenge the decision.
If any part of the letter is unclear, contact your insurance provider for clarification to ensure you have all the details needed to strengthen your appeal. Here are some of the most common causes of claim denials and how they impact your coverage:
Insurers reject claims if they determine the treatment doesn't meet their medical necessity criteria. This means they see the procedure as optional or believe there are more cost-effective alternatives.
Receiving care from a provider not listed in your plan’s network often results in claim rejections. Many policies limit coverage to in-network providers, even for necessary treatments.
Policies have financial caps on specific treatments. If your care exceeds these limits, the insurer denies further payments, leaving you responsible for the remaining costs.
Claims lacking the required paperwork, such as medical records or supporting notes, are denied. Submitting all required documents helps the insurer assess the claim properly.
Every insurance plan has exclusions. If your treatment falls outside what's covered (like certain alternative therapies or elective procedures) your claim gets denied.
Have all the required paperwork to strengthen your appeal and address your insurer's concerns. Here are the key documents you'll need:
Organize your documents in a clear, accessible way to make the appeal process easier. Use physical or digital folders labeled by category, such as "Denial Letters," "Medical Bills" and “Policy Documents,” so you can quickly find the information you need throughout your appeal.
In addition to arranging your documents, set up a record-keeping system for your communications. Log every interaction with your insurance company during the appeal process, noting the date, representative's name and key points discussed. Track deadlines and set reminders to stay on top of appeal timelines and responses.
An internal appeal is your opportunity to ask your insurance company to reconsider their decision. It lets you present new evidence, clarify misunderstandings or challenge the denial based on your policy's details.
Time limits for filing an internal appeal vary by insurer, ranging from 30 to 180 days after receiving the denial notice, so act promptly. To file an internal appeal, follow these steps to present a strong case and start the process:
If a treatment delay puts your health or life at risk, contact your insurer immediately to request an expedited appeal. Explain the urgency and ask your health care provider for a supporting statement. Insurers usually must decide within 72 hours, so track all communications and follow up if needed.
Insurance companies have timelines for responding to appeals. For pending treatments, expect a response within 30 days. For completed treatments, the timeframe is 60 days. Expedited appeals for urgent situations usually have a 72-hour deadline. Mark these dates on your calendar to track when a response is due.
If you don't hear back by the deadline, contact your insurer by phone or email. Reference your case details, such as the appeal filing date and claim number, and ask for an update. A simple follow-up message could be: “*I'm checking on the status of my appeal filed on [date] for claim [claim number]. Please provide an update.*”
Track every interaction with your insurance company during the appeal process. Keep a log of all phone calls, emails and letters, noting the date, representative's name and key points discussed. A spreadsheet or dedicated notebook helps you stay organized and provides a clear record if you need to escalate your appeal.
An external review is an independent evaluation of your denied claim by a third party rather than your insurer. Unlike an internal appeal (where your insurance company reviews its own decision) an external review offers an unbiased assessment that can overturn the insurer's denial based on your policy details and medical evidence.
You can file an external review if your internal appeal is denied or the claim involves medical judgments (such as determining medical necessity) or policy exclusions impacting your coverage. Check your insurer’s guidelines to confirm eligibility, as some claims might not qualify for this process.
If you’re eligible, prepare a concise review request: introduce your case, state your claim details, explain why the internal appeal decision was incorrect and attach supporting documents like medical records or statements from your health care provider.
Filing an external review involves several steps to strengthen your case:
Timelines for external reviews differ depending on the urgency. Standard reviews take around 45 days, while expedited cases are resolved within 72 hours. To avoid delays, stay proactive and respond promptly to any requests from the reviewer.
If your appeal is denied, you still have options to challenge the decision. Consulting a lawyer, filing a complaint with state regulators or seeking mediation all help you push for the coverage you need.
If all appeals fail, consult a lawyer specializing in health insurance law. These professionals review your case in detail, determine if the insurer violated laws and guide you through potential actions like filing a lawsuit. This step works best when you suspect that your rights have been violated or if there are complexities in your case requiring formal legal action.
Submitting a formal complaint to your state's insurance department can lead to an investigation into your insurer's conduct. Each state has an insurance regulator, with complaint procedures available on their website. Make sure to provide complete documentation, including denial letters, policy details and a summary of your appeal efforts, to support your case.
Patient advocates specialize in insurance appeals and can help gather evidence, communicate with your insurer and navigate the appeals process. Contact an advocate if the process feels overwhelming or you're unsure how to proceed.
A neutral mediator can help you and the insurer negotiate a settlement out of court. If mediation fails, litigation is your final option. Lawsuits usually take one to three years and require extensive documentation and legal fees.
To help you better understand and manage appealing your health insurance claim denial, we've answered some of the most frequently asked questions.
Success rates for health insurance appeals vary, but research indicates that over 80% of prior authorization appeals result in insurers partially or fully overturning their initial denials. The chances of success depend on the reason for the denial, the quality of your supporting evidence and how thoroughly you approach the appeals process.
You can resolve a denied claim through an internal appeal, filing an external review or providing additional information to address the reason for the denial. If these steps don't work, seeking legal advice, filing a complaint with state regulators or mediation offer further solutions.
Most insurers give you between 30 and 180 days to file an internal appeal from the date of the denial notice. Review your insurer's timelines and act quickly to avoid missing the appeal window.
If you miss the appeal deadline, contact your insurer immediately to see if they'll grant an extension, as some insurers allow extra time for valid reasons. You can also explore external options, like filing a complaint with state regulators or consulting a lawyer to understand any additional recourse available.
Yes, you can appeal a denied claim multiple times, particularly if new evidence or additional supporting documentation becomes available. However, check your insurer's guidelines to understand the number of appeals permitted and whether external review is available after multiple denials.
Explore these MoneyGeek resources to find tips on comparing health insurance, choosing the best plan, reducing medical bills and managing medical debt effectively.
About Nathan Paulus
Nathan Paulus is the Head of Content Marketing at MoneyGeek, with nearly 10 years of experience researching and creating content related to personal finance and financial literacy.
Paulus has a bachelor's degree in English from the University of St. Thomas, Houston. He enjoys helping people from all walks of life build stronger financial foundations.
