If your health insurer refuses to pay, start with the written denial and Explanation of Benefits (EOB), identify the exact reason and deadline, then file the plan’s internal appeal with evidence that answers that reason. Many qualifying denials can go to an independent external review after the internal decision; urgent cases may qualify for an expedited route or simultaneous external review. The precise rules depend on the plan, state and coverage type, so the denial notice and your plan’s claims procedure control.
What a denial means—and what it does not mean
A denial is the plan’s decision not to pay all or part of a claim or not to authorize requested care. It may concern a service you have not received, treatment already provided, a particular doctor or facility, prior authorization, or the amount the plan will pay. A denial is not necessarily the end of the process: you generally have a right to challenge it through an internal appeal, and some denials can then be reviewed by an independent reviewer.
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Read the denial letter and EOB together. The letter should state why the claim was denied and explain how to dispute the decision. The EOB usually shows the service date, billed amount, allowed amount, what the plan paid, and your stated responsibility. Keep both documents, including every page and attachment.
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Scan for outdated or missing drivers - takes under a minuteDriver Scan →Repair Windows errors before they cause bigger problemsFix Now →Fix the driver behind crashes, sound loss and screen glitchesFind Drivers →This guide addresses the broad U.S. process described by HealthCare.gov for plan appeals and by the U.S. Department of Labor (DOL) for employer health benefits covered by ERISA. Medicare, Medicaid, federal employee coverage, Marketplace eligibility appeals and state-specific procedures can use different stages and deadlines. If you have one of those forms of coverage, follow its official notice and program rules rather than assuming the timelines below apply.
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Step 1: Identify exactly what was denied
Before writing an appeal, make a one-page case summary. Record:
- The date you received the denial and the date printed on it.
- Your name, member or health insurance ID number, claim number and group number, if shown.
- The patient, provider, facility, service or medication, and date of service.
- Whether the issue is prior authorization, medical necessity, an exclusion, lack of coverage, coding, network status, timely filing, or a payment calculation.
- The exact denial language and every plan provision or policy section the insurer cites.
- The deadline, filing address, portal, fax number and any required form.
Do not rely on a phone representative’s summary when the written notice is available. If the EOB and letter appear inconsistent, list the discrepancy and ask the plan to clarify it in writing.
Step 2: Confirm which appeal rules govern
The instructions in the denial notice and the plan’s claims procedure are the controlling starting point. For job-based coverage, request the Summary Plan Description (SPD) from the plan administrator or human-resources benefits office. The DOL’s ERISA guidance says to check the SPD and claims procedure because a plan may provide more time or additional appeal levels than the federal minimum.
HealthCare.gov’s general appeal information concerns an insurer’s decision about a covered claim. It is different from an appeal of a Marketplace determination about whether you are eligible to enroll or receive financial assistance. A refusal to pay a claim goes to the health plan; a Marketplace eligibility decision follows the Marketplace’s separate appeal process.
Also determine whether the claim is:
- Pre-service: the care has not yet occurred and authorization is being requested.
- Post-service: the care has already occurred and the plan is deciding whether to pay.
- Urgent: waiting for the standard process could seriously jeopardize life, health, or the ability to regain maximum function.
Those categories affect notice and decision times. If you cannot tell which category applies, ask the plan and your clinician, but continue preparing the appeal while you seek an answer.
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Step 3: Mark the deadline and request the claim file
Under HealthCare.gov’s general internal-appeal guidance, you have 180 days after receiving the denial to file. The DOL says an ERISA claimant has at least 180 days and that the plan may allow longer. “Received” can matter when a notice is mailed, so use the date and delivery information in the notice and confirm the calculation with the plan procedure.
Request relevant claim documents, records and other information from an ERISA plan. The DOL says those materials may be requested free of charge. Ask for the clinical rationale, medical-review criteria, coding information, records considered by the reviewer and any correspondence that explains the decision. Make the request promptly, but never let a records request make you miss the appeal deadline. File a timely appeal with the information you have and state that additional records will be supplied when received.
Use a calendar reminder several days before the deadline. If the notice gives a different period, follow that written instruction unless the plan confirms an extension in writing.
Step 4: Gather evidence that answers the stated reason
An effective appeal is not a general complaint about the bill. It connects each denial reason to a fact, plan term or clinical explanation supporting reversal. Assemble copies of:
- The denial notice, EOB and any earlier authorization or coverage decision.
- The relevant SPD or certificate-of-coverage language, including definitions, exclusions and authorization rules.
- Itemized bills, claim forms, medical records, test results, prescriptions and treatment history relevant to the disputed service.
- Prior authorization numbers, referrals, provider notes and proof that required steps were completed.
- A focused letter from the treating clinician addressing the insurer’s specific rationale. Ask the clinician to explain the diagnosis, the requested service, why it is appropriate for your circumstances, what alternatives were tried or are unsuitable, and the foreseeable harm of delay when relevant.
- Documentation of an administrative error, such as an incorrect code, wrong patient, duplicate claim or provider misclassification.
Send copies and keep originals. Number the attachments and refer to them by name in the appeal. Keep a call log with the date, representative’s name or ID, reference number, what was said and any promised follow-up. HealthCare.gov specifically recommends retaining the EOB, denial, appeal request, supporting information and call notes.
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Step 5: Write the internal appeal
Use the insurer’s form if one is required. If the notice permits a letter, include the identifying information the plan needs and make the requested remedy unmistakable.
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- Identify the claim. State your name, member ID, claim number, patient, provider, service and date.
- State the action requested. Ask the plan to overturn the denial and pay or authorize the specified service, or to correct the identified processing error.
- Quote or accurately summarize the denial reason. Address each separate reason rather than arguing against a different issue.
- Explain why the decision is wrong. Apply the plan language to the facts, and explain the clinical evidence in plain language.
- List supporting documents. Use attachment numbers and identify the page that supports each material point.
- Request the applicable review level. Ask for an expedited review when the medical standard is met and state why delay creates serious risk.
- Sign and date the submission. Include a safe way for the plan to contact you.
Submit it only through a method listed in the denial notice: the plan portal, designated email, fax, mail address or another accepted channel. Save the completed form, letter and every attachment. Keep proof of submission, such as a portal confirmation, fax transmission report, certified-mail record or dated receipt. A state Consumer Assistance Program may be able to help file an appeal.
Step 6: Ask for expedited handling when delay could cause serious harm
Tell the plan and your treating clinician immediately if waiting for the standard schedule could seriously jeopardize your life, health or ability to regain maximum function. Ask exactly how the plan accepts an expedited internal-appeal request and what medical certification it requires. Your clinician’s statement should explain the time-sensitive risk, not merely say that the treatment is preferred.
HealthCare.gov says an urgent external-review request may, in qualifying cases, be filed before the internal appeal is complete or at the same time. The eligibility test and filing route depend on the plan and applicable state or federal process. Do not assume that labeling a case “urgent” automatically changes the deadline; obtain the plan’s instructions and document when you made the request.
Step 7: Track the plan’s response
HealthCare.gov’s general guidance gives these timeframes for plan notices and internal decisions:
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| Event | General timing | Qualification |
|---|---|---|
| Notice after a request for prior authorization | 15 days | HealthCare.gov general internal-appeal guidance; the plan and circumstances can affect the rule. |
| Notice for care already received | 30 days | HealthCare.gov general internal-appeal guidance. |
| Notice for urgent care | 72 hours | HealthCare.gov general internal-appeal guidance. |
| Decision for service not yet received | 30 days | HealthCare.gov general internal-appeal guidance. |
| Decision for service already received | 60 days | HealthCare.gov general internal-appeal guidance. |
| ERISA urgent review | As soon as possible, no more than 72 hours | DOL guidance; the plan’s procedure supplies operational details. |
| ERISA pre-service review | No more than 30 days | DOL guidance. |
| ERISA post-service review | No more than 60 days | DOL guidance. |
These are general source-specific timeframes, not a guarantee for every policy. If the plan misses a required deadline, ask for the reason and the next remedy in writing, and contact the appropriate regulator or consumer-assistance office. Do not treat silence as approval unless the governing rule expressly says so.
Step 8: Read the internal decision for your next right
The plan should send a written decision. If it reverses the denial, verify the authorization dates, units, provider and payment instructions; an approval that omits part of the service may require clarification. If it upholds the denial, mark:
- Every reason for the final decision and the plan provisions cited.
- Whether another voluntary appeal level is available.
- Whether the issue qualifies for external review.
- The external-review administrator, form, address and deadline.
- Instructions for obtaining documents and any judicial-review rights that apply to an ERISA plan.
For ERISA plans, the DOL says a final decision must give specific reasons, cite the relevant plan provisions, explain rights to relevant documents and describe available voluntary procedures and judicial-review rights. Preserve the final letter with the rest of the file.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.Step 9: Request independent external review when available
External review moves the decision outside the insurer. As HealthCare.gov puts it, “External review means that the insurance company no longer gets the final say over whether to pay a claim.” Eligibility is not universal. HealthCare.gov describes external review for certain decisions involving medical judgment, experimental or investigational treatment, and some coverage cancellations. Administrative denials or issues outside the applicable benefit may not qualify.
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Repair common Windows errors and clear accumulated junk for a smoother, more stable PC - no reinstall needed.Free scan · no reinstallFollow the final denial notice exactly. HealthCare.gov describes a general four-month period after receipt of the final determination to request external review. The administrator may be a state process, an HHS federal process or an independent review organization, depending on the plan and jurisdiction. A written request normally must identify the denial, include the final decision and provide the records the reviewer needs.
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| External-review stage | General timing | Who controls the details |
|---|---|---|
| Request after final denial | Generally within 4 months | Follow the final notice and the applicable state or federal process. |
| Standard decision | No later than 45 days | HealthCare.gov general external-review guidance. |
| Expedited decision | No later than 72 hours, or sooner when medical urgency requires | HealthCare.gov general external-review guidance. |
HealthCare.gov notes that a time-limited 2026 extension may affect certain HHS-administered federal external-review deadlines. Because eligibility and dates are notice-specific, check the live instructions in your final denial rather than relying on a general calendar assumption.
For an urgent case, ask whether the external request can be filed before the internal appeal ends or concurrently. The plan or reviewer may require a clinician’s certification and a separate urgent channel.
Internal appeal versus external review
| Feature | Internal appeal | External review |
|---|---|---|
| Reviewer | The health plan or insurer | An independent reviewer or organization designated by the applicable state or federal process |
| When available | Usually the first formal challenge after a denial | Generally after a final internal denial; qualifying urgent cases may proceed before completion or concurrently |
| Typical qualifying issues | Coverage, authorization, medical-necessity and payment disputes covered by the plan procedure | Certain medical-judgment, experimental or investigational and specified cancellation decisions |
| General filing period | 180 days after receiving the denial under HealthCare.gov guidance; ERISA plans must allow at least 180 days and may allow longer | Generally 4 months after the final denial under HealthCare.gov guidance |
| General decision time | 30 or 60 days for many standard cases; 72 hours for urgent care under HealthCare.gov guidance | Up to 45 days standard or 72 hours expedited under HealthCare.gov guidance |
| Administrator | Your plan’s claims and appeals unit | State process, HHS federal process or another designated independent review organization |
The table describes general pathways, not a promise that every policy offers external review or uses these exact dates.
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- Missing the deadline while waiting for records. File on time and supplement later if the procedure permits.
- Arguing without addressing the denial code. Start with the insurer’s stated reason and answer it point by point.
- Sending originals. Retain originals and submit copies or secure electronic files.
- Relying on phone calls alone. Use a written appeal and preserve confirmation of delivery.
- Ignoring the plan language. Quote the relevant definition, exclusion or authorization requirement and explain why it does not apply or was satisfied.
- Assuming every denial is externally reviewable. Check the final notice for eligibility and the administrator.
- Confusing a claim denial with Marketplace eligibility. Use the correct appeal system for the decision you are challenging.
- Calling a case urgent without medical support. Explain the concrete risk of delay and obtain clinician documentation.
Where to get official help
HealthCare.gov directs consumers to state Consumer Assistance Programs and state Departments of Insurance for help with internal appeals and external review. For employer coverage, it directs consumers to the DOL’s Employee Benefits Security Administration (EBSA). Have your denial, EOB, SPD or claims procedure, appeal copy and call log ready before contacting an agency. A folder—paper or digital—is sufficient; no special product is required.
When you call, ask which rule governs your plan, whether the deadline has been calculated correctly, where to send the appeal, whether expedited review is available, and which external-review route applies after a final denial. Record the representative’s name, date, reference number and instructions.
Quick Recap
A final pre-submission checklist
- I can state the exact claim, service and denial reason.
- I confirmed the governing plan procedure and deadline.
- I included my identifying information and requested remedy.
- I answered each denial reason with plan language and supporting facts.
- I attached the EOB, denial, relevant records and clinician letter, keeping originals.
- I requested expedited handling and supplied urgency documentation if appropriate.
- I used the required channel and saved proof of submission.
- I calendared the expected decision date and the external-review deadline.
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