How to appeal a health insurance denial
In recent data, insurers on the federal marketplace denied roughly 19% of in-network claims, and fewer than 1% of those denials were appealed. Of the appeals that were filed, about a third overturned the denial. The appeal deadlines are strict, so note them before you start.
- Internal appeal (within 180 days). You ask the insurer in writing to reconsider, and the law requires it to answer, generally within 30 days for care you haven’t received yet and 60 days for care you already got. Urgent cases are expedited.
- Demand their criteria. The insurer must tell you the specific reason for the denial and, if you ask, the clinical criteria behind it. Asking for the rule and the reviewer’s specialty can show that a denial doesn’t hold up.
- External review (within 4 months of the final denial). An independent review organization decides, and the insurer is bound by the result. Standard decisions come in 45 days, urgent ones in 72 hours or less.
Who regulates my insurer?
If you bought your plan yourself or through the marketplace, or your employer’s plan is fully insured, your state insurance department takes complaints and runs external review. If your employer self-funds its plan, it falls under federal ERISA rules and the U.S. Department of Labor (1-866-444-3272). The playbook shows how to tell which kind of plan you have.
What makes an appeal stronger
A letter of medical necessity from your treating physician, the plan’s own coverage language, and peer-reviewed support, laid out the way reviewers expect to see them. The letters give you that structure, and you supply the documents.
Insurance Appeal Letters provides self-help document templates and general information. It is not legal or medical advice, it is not a law firm, an insurance advisor or a patient advocacy service, and it is not a substitute for the advice of an attorney. Appeal rights and deadlines vary by plan type and state and change over time, so check the current rules at healthcare.gov or with your state insurance department. Statistics are from a KFF analysis of 2024 marketplace data.