When Health Insurance Says No: How to Appeal

The envelope says the claim was denied, the bill is suddenly yours, and the letter is written like the conversation is over. It isn't. Federal law gives you the right to make your insurer look again (an internal appeal), and if they still say no, the right to an independent outside reviewer whose decision binds them (an external review). Insurers reverse themselves on appeal far more often than people expect. The catch is that almost nobody appeals: studies of marketplace plans have found fewer than 1% of denied claims are ever challenged.

The letter (or the explanation of benefits) must state a reason. Most denials fall into a few buckets: a paperwork error, 'not medically necessary,' 'out of network,' or 'prior authorization required.' A surprising share are simple coding mistakes, a wrong digit between the doctor's office and the insurer, and those can dissolve with one phone call asking the provider to rebill.

1. 1Call the number on your card and ask exactly why the claim was denied and what would change the decision. Write down the date and the rep's name.
2. 2Ask your doctor's office for help. A 'letter of medical necessity' from the doctor is the single strongest attachment an appeal can have, and offices write them all the time.
3. 3Send the appeal in writing before the deadline (plans must give you at least 180 days). Include the claim number, the reason the denial is wrong, the doctor's letter, and any records.
4. 4Keep copies of everything and send it in a way you can prove arrived.

An appeal is not a complaint; it's a case. 'The denial says not medically necessary, and here is my doctor's letter explaining why it is' beats ten paragraphs about how unfair this feels.

If the internal appeal fails, the denial letter must explain how to request an external review by an independent third party, generally within 4 months. It's free or nearly free, you can attach everything from your internal appeal, and if the reviewer sides with you, the insurer must pay. For urgent care situations, both levels can be expedited to days instead of weeks.

Don't ignore the bill in the meantime; tell the provider's billing office an appeal is in progress and ask them to pause collections. Most will. If the appeal ultimately fails, you're not out of moves: how to fight a medical bill covers financial assistance, self-pay discounts, and payment plans, and free legal help exists for the big ones.