Your Action Plan: Insurance Denial Appeal

Time-sensitive

Most denials can be overturned. The insurance company is counting on you not to appeal.

Appeal deadlines are strict. Check your denial letter or EOB for your specific deadline. For ACA and employer plans, internal appeal deadlines are typically 180 days. For Medicare, the deadline is 120 days. If your situation is urgent (ongoing care or serious condition), you have the right to an expedited appeal that must be resolved in 72 hours.

Start here

Find your appeal deadline on your denial letter or EOB — then ask your treating doctor to write a letter of medical necessity.

In your favor

75% of appealed Medicare Advantage denials are overturned, yet fewer than 1% of patients ever file an appeal. Filing costs you nothing.

Your Action Steps

Find four things: (1) the specific denial reason, (2) the clinical policy cited, (3) your appeal deadline, and (4) the appeals address or fax number. If you didn’t receive a written denial, request one — your insurer is required to provide it.

You have the right to see the specific medical policy or clinical guideline used to deny your claim. Having this document lets you address their exact reasoning in your appeal.

What to say

“I’d like a copy of the clinical criteria or medical policy used to deny my claim.”

This is the single most important piece of your appeal. Your doctor can explain why the treatment was medically necessary, cite clinical guidelines, and address the insurer’s specific denial reason. Doctor involvement dramatically improves appeal outcomes.

Resources

Guides on This Topic

Insurance Claim Denied? How to Appeal Know Your Medical Billing Rights Surprise Medical Bills and the No Surprises Act Medicare Advantage Fraud: How Insurers Overbill Taxpayers

Free Tools & Organizations

Patient Advocate Foundation

Free case management and appeals assistance for patients dealing with insurance denials, especially for serious or chronic conditions.

NAIC State Insurance Department Map

Find your state insurance department to file a complaint about claim denial practices.

CMS Medicare Appeals

Official Medicare appeals process information, including deadlines and forms for each level of appeal.

Department of Labor — ERISA Health Plan Appeals

Information about appeal rights for employer-sponsored (ERISA) health plans.

Educational Information Only

This information is educational and does not constitute legal, medical, or financial advice. Laws and programs vary by state and change over time. For complex situations — particularly lawsuits, wage garnishment, or situations involving large sums — consult a qualified attorney, patient advocate, or other professional. We connect you with free resources that can help.