How to Appeal a Health Insurance Claim Denial in 5 Steps

People file claims with their health insurance provider to help cover the cost of essential medical care like doctor visits or unexpected treatments. Claim denials happen for many reasons, from out-of-network providers and missing documents to disputes over what's covered. Such denials can leave you feeling overwhelmed and facing costs you thought were covered.

But a denied claim doesn’t have to be the final word. By understanding why the claim was rejected, gathering the right documents and knowing how to appeal through internal and external reviews, you improve your chances of getting your claim approved.

To appeal a denied health insurance claim, pinpoint the reason for the denial, gather the necessary documents, file an internal appeal and, if needed, pursue an external review. 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, don’t hesitate to reach out to 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:

Have all the required paperwork to strengthen your appeal and address your insurer's concerns. Here are the key documents you'll need:

• Denial letter or EOB
• Original claim and related medical bills
• Policy documents (e.g., summary of benefits, explanation of coverage)
• Supporting medical records from your health care provider

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:

1. Contact your insurance company’s customer service for specific instructions on how to initiate the appeal.
2. Request reconsideration during your call by stating your reasons for disputing the denial. Note down the conversation details, including the representative's name and any guidance given.
3. Ask your health care provider to resubmit claims with any additional or corrected information that support the appeal.
4. Write your appeal letter after gathering all necessary information. Structure it clearly and compellingly:
   • Introduction: Reference your denied claim and briefly state your case.
   • Explanation: Clarify why the denial was incorrect, citing policy documents or coverage terms.
   • Evidence: Include supporting documents like doctor’s notes, medical records or research showing the medical necessity of the treatment.
   • Call to Action: Request full reconsideration and reimbursement.

Insurance companies have specific 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. Using 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:

1. Contact the independent third-party reviewer assigned to your case. Your insurer will provide instructions on how to initiate the process.
2. Complete all required forms necessary for the review. The forms may vary based on your claim type and the reviewer's protocols.
3. Submit supporting evidence relevant to your case. Include any updated medical records, statements from your provider and additional documents that strengthen your appeal.
4. Track all submissions by noting the dates and keeping copies of every document sent. This will help you track the status and follow up when needed.

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.

To help you better understand and manage appealing your health insurance claim denial, we've answered some of the most frequently asked questions.

Explore these MoneyGeek resources to find tips on comparing health insurance, choosing the best plan, reducing medical bills and managing medical debt effectively.