Health Insurance Denial Appeal Guide

Start here: which rulebook applies to you

• Your insurance card and plan name

  The card tells you the plan and the member ID every document has to reference

• Summary Plan Description or Summary of Benefits

  For an employer plan, the SPD is the governing document -- it says what is covered and how appeals work

• Whether your employer plan is self-funded

  Ask HR or check the SPD. Self-funded plans use the federal external review route, not your state insurance department -- 29 C.F.R. section 2590.715-2719(c)(1)(ii)

• Medicare Summary Notice or plan denial notice

  For Medicare, the notice names the level you are at and the deadline for the next step

• Medicaid notice of action

  The date of action printed on this notice is the deadline that decides whether your benefits keep running during the appeal

The denial itself

• Denial letter or adverse benefit determination

  The written decision stating the reason -- not medically necessary, experimental, not covered, out of network, or no prior authorization

• Explanation of benefits

  The EOB showing what was billed, allowed, paid, and denied, with the reason and remark codes

• Appeal instructions and deadline

  The procedure that came with the denial, including where to send the appeal and how many internal levels the plan has

• The clinical criteria the plan applied

  If the letter names a medical policy, guideline, or criteria set, get that document -- your appeal has to meet it or show why it does not fit

• Claim number, dates of service, and billing codes

  The CPT and diagnosis codes on the claim, which is where coding-error denials are found and fixed

The plan file you are entitled to

• Written request for your complete claim file

  Under 29 C.F.R. section 2560.503-1(h)(2)(iii), an ERISA plan must give you copies of everything relevant to the claim, free of charge

• The reviewer's notes and credentials

  Who reviewed it, in what specialty, and what they recorded -- a denial reviewed by someone outside the relevant specialty is worth pointing out

• Prior authorization records

  If the treatment was approved in advance and then denied after the fact, the approval is among your strongest exhibits

• The plan's internal correspondence about your claim

  Often reveals the guideline actually applied, which may differ from the reason quoted in the letter

Medical evidence that answers the stated reason

• Letter of medical necessity from your treating doctor

  Not a general endorsement -- a letter that takes each reason in the denial in turn and answers it

• Office notes and treatment history

  Chronological records showing the diagnosis, what was tried, and how you responded

• Proof that required alternatives failed

  For step therapy denials, documentation that the cheaper drugs or treatments were tried and did not work or could not be tolerated

• Test results and imaging

  Labs, scans, and reports that establish the condition the treatment addresses

• Published clinical literature

  For experimental or investigational denials, peer-reviewed studies and specialty society guidelines supporting the treatment

• Second opinion or specialist letter

  An independent physician who agrees the treatment is appropriate carries weight with an outside reviewer

Billing, network, and coverage records

• Itemized bill from the provider

  The bill and the EOB must be reconciled -- appeal the denial on the EOB, not the balance on the bill

• Proof of network status

  Screenshots of the plan directory with dates, or written confirmation the provider was in network on the date of service

• Referral or authorization numbers

  Any reference number the plan gave you when it approved a visit, procedure, or drug

• Formulary and coverage documents

  For prescription denials, the formulary page showing the tier, restrictions, and exception process

Escalation after the internal appeal

• External review request form

  For the federal process, the request is due within four months after you receive the final internal denial -- 29 C.F.R. section 2590.715-2719(d)(2)(i)

• State insurance department complaint

  For a fully insured plan, your state department of insurance takes complaints and runs the state external review process

• Department of Labor inquiry

  For an employer plan, the Employee Benefits Security Administration takes questions about a plan's handling of claims

• Medicare next-level request

  Each Medicare notice tells you the deadline and the address for the next level in the ladder under 42 U.S.C. section 1395ff

• Medicaid fair hearing request

  Requested under 42 C.F.R. section 431.220, in writing, with a copy of the notice of action attached

How long do I have to appeal a health insurance denial?

It depends on who governs your plan. For an employer plan governed by ERISA, 29 C.F.R. section 2560.503-1(h)(3)(i) requires at least 180 days from the date you received the adverse benefit determination -- that is a floor, and your plan may allow longer, so the date on the denial letter controls. Medicare and Medicaid run on their own deadlines printed on each notice you receive. Whatever the rule, treat the earliest date you can find as the real one, and file something in writing before it passes even if your records are not complete.

What is external review and when can I use it?

External review sends your denial to an independent review organization that is not employed by your plan, and the decision binds the insurer. You reach it after exhausting the plan's internal appeals. It generally covers denials involving medical judgment -- medical necessity, appropriateness, level of care, or experimental and investigational determinations -- along with rescissions of coverage. Denials that rest purely on eligibility are usually outside it. For the federal process, the request is due within four months after you receive the final internal denial, under 29 C.F.R. section 2590.715-2719(d)(2)(i).

My employer plan is self-funded. Does my state insurance department help?

Generally no. Under 29 C.F.R. section 2590.715-2719(c)(1)(ii), a self-insured plan follows a state external review process only where that process is not preempted by ERISA, and for an ordinary private-employer self-funded plan it is. Those plans use the federal external review process instead, and the denial letter should name the process or the review organization to contact. Self-funded plans sponsored by a state or local government, or by a church, are the main exceptions. Ask HR whether the plan is self-funded before you file anything with the state, because the wrong forum costs you weeks.

Can I get my plan's file on my claim?

For a plan governed by ERISA, yes. 29 C.F.R. section 2560.503-1(h)(2)(iii) requires the plan to give you, on request and free of charge, reasonable access to and copies of all documents and records relevant to your claim. Ask in writing, and ask specifically for the clinical criteria applied, the reviewer's notes and specialty, and any internal correspondence. This is worth doing before you draft the appeal rather than after, because the file frequently shows which guideline was actually used -- which is not always the reason quoted in the letter.

Will my Medicaid benefits stop while I appeal?

Not if you act before the date of action on the notice. Under 42 C.F.R. section 431.230(a), benefits continue through the hearing decision where the agency sent advance notice and you requested the hearing before that date. This is a different and earlier deadline than the general request window, which 42 C.F.R. section 431.221(d) caps at 90 days from the date the notice was mailed. One caution: if the hearing upholds the agency, 42 C.F.R. section 431.230(b) permits it to recover the cost of services furnished solely because your benefits continued, so it is a decision worth making with the risk in view.

How should I organize an appeal packet?

Number each document as an exhibit and open with a cover letter that lists them and says in one line what each one shows. Then structure the letter by the plan's own denial reasons: quote the reason, point to the exhibit that answers it, and state your conclusion. Health appeal packets often run to several hundred pages of records, so labeled exhibits and an index are what let a reviewer follow the argument instead of skimming. ExhibitPrep makes it easy to add exhibit labels to your PDFs and combine them into one indexed file.