You did everything right—saw a doctor, submitted your claim, followed your insurance plan’s rules—and then came the letter:
“Claim denied.”
But don’t panic. You have the right to appeal your health insurance provider’s decision—and you absolutely should, especially if the denial doesn’t make sense.
In this guide, we’ll walk you through exactly how to file a health insurance appeal, what to include, and how to improve your chances of success.
🧠 What Is a Health Insurance Appeal?
A health insurance appeal is a formal request asking your insurance company to review and reconsider a denied claim, service, or medication.
Appeals can involve:
- Denial of treatment or surgery
- Refusal to cover medications
- Claim rejections for services you already received
- Being billed for something your plan should have covered
💡 You have a legal right to file an appeal—and often multiple levels of appeal—under federal law and your state’s insurance regulations.
🩺 Step 1: Understand Why the Claim Was Denied
Start by reviewing your:
- Explanation of Benefits (EOB)
- Denial letter from your insurance company
Look for:
- The denial code and reason
- The specific policy or clause cited
- Instructions for how to appeal and deadlines
Common reasons for denial:
- Service deemed “not medically necessary”
- Out-of-network provider
- Prior authorization not obtained
- Incorrect billing code
- Missed filing deadlines
🧾 Step 2: Gather Supporting Documents
To make a strong case, you’ll need:
- A copy of the denial notice or EOB
- Medical records and provider notes
- Doctor’s letter of medical necessity
- Referrals or authorizations (if applicable)
- Any communication with your insurer or provider
- The relevant section of your insurance policy (plan summary or SPD)
🧠 If your doctor supports your appeal, ask them to write a detailed letter explaining why the denied treatment or service is necessary.
📬 Step 3: Write Your Appeal Letter
You can often use your insurer’s appeal form, but it’s usually more effective to include a custom letter. Here’s what to include:
📌 What to Put in Your Appeal Letter:
- Your name, plan number, and contact info
- The specific service or claim you’re disputing
- Date of service and provider name
- The reason for denial (quote from the letter or EOB)
- A clear explanation of why you believe the denial is incorrect
- Supporting documentation (listed and attached)
- A request for full coverage of the denied service
🖊️ Keep it factual, respectful, and concise. Stick to medical facts and policy details.
⏳ Step 4: File the Appeal Within the Deadline
Timing is crucial.
- Most insurers require appeals to be filed within 180 days (6 months) of the denial.
- Some allow online submissions; others require mail or fax.
Make copies of everything you send and note the date. If mailing, use certified mail or tracking.
🏛️ Step 5: Follow Up and Be Persistent
Once submitted:
- You should receive a confirmation of your appeal
- Insurers typically respond within 30–60 days
- If denied again, you may have additional options:
- Second-level internal appeal
- External review by an independent third party (your right under federal law)
💬 Don’t be afraid to call and ask for updates. Keep detailed notes of every conversation.
🚨 Expedited Appeals
If you’re facing an urgent medical situation, ask for an expedited appeal—often reviewed within 72 hours.
Qualifying examples:
- A delay in treatment could seriously jeopardize your health
- Denial involves ongoing hospitalization or life-saving medication
🧠 You May Wanna Check Out:
✅ Final Thoughts
Claim denials happen—but that doesn’t mean your insurance company gets the last word.
By understanding the reason for denial, gathering strong documentation, and submitting a clear, timely appeal, you can fight back effectively—and often get the coverage you deserve.
Don’t give up. Persistence and preparation are your best legal weapons.
