How to Appeal a Denied Health Insurance Claim

A claim came back denied, the letter is pages of codes, and the balance has moved to the patient side. The healthcare.gov overview of appealing a health plan decision describes two stages, an internal appeal and then an external review, and says the insurer no longer gets the final say at the second one.

Read the denial notice for the reason and the filing instructions

That page states insurers have to tell you why they denied a claim and how to dispute it, so both are on the notice. The healthcare.gov page on internal appeals lists the denials that can be appealed, among them a benefit not offered under the plan, a provider outside the network, and a service labeled not medically necessary.

Pull the explanation of benefits and copy the file

That page lists the papers to keep: the Explanation of Benefits forms or letters showing what was denied, the appeal request, and anything sent with it. It says to keep the originals, submit copies, and count notes from calls as part of the record, with the day, time, name, and title of anyone spoken to.

File the internal appeal inside the stated window

It states an internal appeal must be filed within 180 days of receiving notice of the denial. It says to complete the forms the insurer requires, or write with the name, claim number, and health insurance ID number, and add anything the insurer should consider, such as a letter from the doctor. It gives the insurer 30 days to decide on a service not yet received and 60 days on one already received, and says the written decision must explain how to ask for an external review.

Ask for the expedited route in an urgent situation

The same page says an expedited appeal is available where the standard timeline would seriously jeopardize life or the ability to regain maximum function, that an internal appeal and an external review request may be filed at once, and that the decision must come within 4 business days, followed by written notice within 48 hours.

Send the denial to independent external review

The healthcare.gov page on external review puts the written request due within 4 months after the denial notice is received, and says the insurer is required by law to accept the external reviewer's decision. It allows 45 days for a standard review and 72 hours or less for an expedited one, and says there is no charge under the HHS-Administered Federal External Review Process, while a state process cannot charge more than $25, as of September 2026. The page links a state list kept by CMS.

If the plan is self-funded through an employer. The Department of Labor page on filing a claim for health benefits says the Summary Plan Description explains how to file, that plans must allow at least 180 days to appeal, and that non-grandfathered plans must provide external review by an independent party. EBSA benefits advisors take calls on 1-866-444-3272.

For help preparing an appeal. The internal appeals page says a state Consumer Assistance Program can file an appeal for you, and CMS keeps a program map pointing to the state department of insurance where none exists.

Sources. Appealing a health plan decision, internal appeals, external review.