How to appeal a health insurance denial - step by step

1. 1

   Read the letter - and find the deadline

   Find the date on the letter, the stated denial reason, and the appeal deadline. The internal-appeal window starts on the date printed on the letter, not when you received it. For most commercial plans you have 180 days; Medicare is 120; Medicaid can be as short as 60.

2. 2

   Request the documents the insurer used

   By federal law your insurer must give you, free of charge, the specific medical policy or criteria they applied, the reviewer's credentials, and any internal guidelines used. Ask in writing and keep the request.

3. 3

   Get your provider on your side

   Ask your doctor or facility for a letter of medical necessity citing your diagnosis (ICD-10), failed prior treatments, and the relevant clinical guideline. Add chart notes, imaging, and labs from the last 6 - 12 months.

4. 4

   Write a focused appeal letter

   Quote the denial reason. Then, point by point, explain why the criteria were actually met using your records and guidelines. Keep it short, factual, and professional - two pages plus attachments is plenty.

5. 5

   Mail it certified, a week early

   Send by certified mail with return receipt at least a week before the deadline. Include the appeal letter, the letter of medical necessity, supporting records, and a copy of the denial letter. Keep everything.

6. 6

   Track the clock - then escalate

   The plan must respond in writing within the timeframes in your Evidence of Coverage (typically 30 days for pre-service, 60 for post-service). If denied again, request an external review by an Independent Review Organization - these reverse a significant share of denials.

Informational only - not legal advice.