How to Appeal a Denied Health Insurance Claim in 2 Steps
Appeal a denied health insurance claim in 2 steps: file an internal appeal within 180 days, then ask for an external review within 4 months.
Last checked
When a health insurance company refuses to pay for a service or treatment, you have the right to challenge that decision. Federal rules give most health plans a two step appeals process: first an internal appeal with the insurer, then an independent external review if the denial stands. Knowing the deadlines for each step keeps the appeal alive, since a missed deadline can end the process.
Summary
An internal appeal asks your insurance company to reconsider its own denial. You must file it within 180 days (6 months) of receiving the denial notice. The insurer must decide within 30 days for care you have not yet received, within 60 days for care you already received, and within 72 hours for urgent care cases.
If the internal appeal fails, you can ask for an external review, where an independent reviewer outside the plan decides the case. You must file the written request within 4 months after the final internal denial. A standard external review is decided no later than 45 days after the request, and an expedited review no later than 72 hours. The insurer is required by law to accept the external reviewer's decision.
| Step | Deadline to file | Decision time |
|---|---|---|
| Internal appeal | Within 180 days of the denial notice | 30 days pre-service, 60 days post-service |
| External review | Within 4 months of the final internal denial | 45 days standard |
| Expedited review | With the internal appeal for urgent care | 72 hours or less |
The table shows why the denial notice matters so much. Both filing clocks run from the date you receive a notice, so the notice sets the calendar for the whole appeal.
Before you start: Read the denial notice
Your insurer must notify you in writing and explain why it denied the claim, and it must explain how you can appeal. The notice deadlines differ by claim type: within 15 days for prior authorization, within 30 days for medical services already received, and within 72 hours for urgent care cases.
Read the notice for three things: the reason for the denial, the deadline printed on it, and the instructions for filing. Reasons can include a service the plan calls not medically necessary or a treatment the plan calls experimental or investigational. Your own deadline may differ from the general rules, so the notice controls.
If you request it, your insurer must provide the information behind its decision, such as the names of experts consulted. Keep copies of everything: the denial notice, the explanation of benefits, your appeal letters, letters from your doctor, and notes from phone calls with names, dates, and details. Submit copies and keep the originals.
Step 1: File the internal appeal
To file an internal appeal, complete the forms your insurer requires, or write to your insurer with your name, claim number, and health insurance ID number. State clearly that you are appealing the denial, and add any information you want considered, such as a letter from your doctor explaining why the care is needed.
File within 180 days of receiving the denial notice. If you have employer sponsored coverage, you may be required to file two internal appeals before you can request an external review, so check your plan documents for that rule.
At the end of the process, the insurer must give you a written decision. If the denial stands, that final internal denial should tell you how to request an external review, so keep it with your records.
Step 2: Ask for an external review
An external review is a review of the denial by an organization that is independent of your insurer. It can cover any denial that involves medical judgment, a determination that a treatment is experimental or investigational, or a rescission of coverage.
File a written request within 4 months after the date you receive the notice or final determination. Your state may run its own external review process that meets or goes beyond the federal standards, and if so, your insurer follows your state process. If your state process does not meet the federal minimum standards, the federal Department of Health and Human Services (HHS) oversees the process for insurers in your state.
A standard external review is decided as soon as possible and no later than 45 days after the request was received. If your health plan participates in the HHS administered federal process, there is no charge. If your issuer contracted with an independent review organization or uses a state process, you may be charged, but the charge cannot exceed $25 per external review.
If care is urgent: Use the expedited path
If the standard timeline would seriously put your life at risk, you can ask for a faster decision. For urgent care, the internal appeal decision must come within 72 hours. For urgent health situations, you may file an external review request at the same time you file for an internal appeal.
An expedited external review is decided as soon as possible and no later than 72 hours, or less depending on the medical urgency, after the request was received. If you have questions about the process, the Marketplace Call Center at 1-800-318-2596 can point you to help, and your state may have a Consumer Assistance Program that can file the appeal for you.
How we chose
This guide follows the order of the federal appeals process as published by the Centers for Medicare and Medicaid Services and HealthCare.gov: notice, internal appeal, external review, and the expedited path. Every deadline in the table comes from those pages, and where a state process or a plan rule can change the timeline, the guide says to check the notice.
Choosing order
- Read the denial notice and note the reason, the deadline, and the filing instructions.
- File the internal appeal within 180 days, with a doctor letter and copies of your records.
- If the denial stands, file a written external review request within 4 months, and use the expedited path when care is urgent.
Before you finish
- Confirm the denial reason and the deadline printed on your notice.
- Check whether your plan requires two internal appeals before external review.
- Confirm whether your state runs its own external review process.
- Check whether your coverage is a grandfathered plan, since plans that existed on March 23, 2010 may not follow the same rules.
- Keep copies of every letter, form, and call note from the appeal.
This article is for general information, not financial advice.