Frequently Asked Questions

Start by carefully reading your denial letter. It will contain the specific reason for the denial and instructions on how to initiate an internal appeal. You will need to submit a formal written request to your insurance company. Using our Appeal Letter Builder is a great first step.

Under the Affordable Care Act, you generally have 180 days from the date you receive the denial notice to file an internal appeal. Deadlines for external reviews are shorter, often 60 days after the final internal denial. Always verify the specific deadline with your state's Department of Insurance.

There is no cost to file an internal or external appeal. The process is free for consumers. Your only costs might be for copying documents or mailing your appeal via certified mail, which is highly recommended.

You must request an Independent External Review. This is your right under federal law. An unbiased third party will review your case, and their decision is legally binding on the insurance company. This is a critical step that many people win.

An external review is an appeal where an Independent Review Organization (IRO)—not your insurer—makes the final decision. The IRO is staffed with clinical experts who were not involved in the original denial. It's designed to be a fair, impartial process.

For most internal and external appeals, you do not need to hire professional help. However, if your case is very complex, involves a high-cost treatment, or if you feel overwhelmed, a certified patient advocate or an attorney specializing in insurance law can be very helpful.

Yes and no. Most employer-sponsored plans are governed by ERISA. They still must follow the ACA's rules for appeals, including the 180-day deadline and the right to an external review. The main difference can be in the options you have for taking legal action if the external review fails.

This doesn't change your appeal rights. Even if your employer pays the claims directly (self-insures), the plan is still administered by an insurance company and must comply with federal appeal laws under the ACA and ERISA.

They are surprisingly high. While exact numbers vary, studies suggest that 40-60% of claims are reversed during the internal appeal process. For cases that go to external review, patients win 40-60% of the time. The data shows that fighting back is often worth it.

The single most important document is a detailed Letter of Medical Necessity from your doctor. Also include your formal appeal letter, relevant medical records, and any peer-reviewed scientific studies that support the treatment.

Be proactive. Schedule a specific time to talk to your doctor about the appeal. Provide them with a copy of the denial letter. Ask them to clearly explain why the treatment is medically necessary for YOU, referencing clinical guidelines and your specific health situation.

An appeal is a legal process. Document every phone call (date, time, person's name) and keep copies of every letter, email, and medical record. This creates a paper trail that can be invaluable if you need to escalate your case.

For standard pre-service claims, insurers must decide an internal appeal within 30 days. For urgent cases, it's 72 hours. An external review typically takes up to 45 days for standard cases.

A second opinion from another doctor can be very powerful, especially if your denial was for 'medical necessity.' If an independent specialist agrees that the treatment is necessary, this adds significant weight to your appeal.

At this point, the standard appeal process is over. Your remaining options are to file a complaint with your state's Department of Insurance or to pursue legal action against the insurance company. This is the stage where consulting with an attorney is most appropriate.