Step 3 of 3 in the journey

You are allowed to ask again.
Then ask someone independent.

Most coverage gives you at least two chances: an appeal the plan decides, and a review by someone outside the plan. Regulators and, at the end, courts sit behind those. The order and the deadlines depend on your coverage.

First appeal? Start with the internal appeal.

What do you need to do?

Fix it without an appeal Get a corrected claim resent, ask for reprocessing, or have your doctor speak to the plan's reviewer.
File an internal appeal Ask the plan to reconsider, in writing, inside your deadline, with proof it arrived.
Get a fast decision when health is at risk Time-sensitive Ask for an expedited appeal when waiting could seriously harm you, and keep treatment going where the rules allow.
Request an independent external review Take the decision to reviewers outside the plan, whose decision the plan must follow.
Complain to a regulator Tell the agency that oversees your plan what it did wrong, and know what the agency can and cannot do.
After a final denial See every option left: the employer, a lawsuit, a new request, the bill, and other ways to get the care.

Tools for this step

Free, no account, nothing leaves your browser.

Appeal tracker
Track each level of your appeal, see the next deadline, and save the dates to your calendar.

Tool
Decision clock
Check whether your plan has taken longer than the law allows to decide, and what you can do if it has.

Tool
Employer escalation builder
Build a request asking your employer's benefits team to step in, with a script for the conversation.

Tool
External review planner
Find out where to file for an independent review in your state, the deadline, the fee and what to send.

Tool
Regulator complaint builder
Find the agency that oversees your plan and draft a short, factual complaint.

Tool
Urgent appeal triage
See whether you can ask for a fast decision, what your doctor must say, and who to call today.

Tool

Start with

16 guides in this area

Guide

How to file an internal appeal

Ask your plan to reconsider a denial, in writing and inside your deadline, and know how long the plan has to answer. Covers job-based plans and individual or marketplace plans.
Guide

Patient appeal and provider appeal: run both

Your doctor's office may appeal on its own, and you can appeal too. Here is how to run both without crossed wires, and how to let the office act for you in writing.
Guide

Second-level internal appeals

Some job-based plans have two internal appeal levels, and some offer an optional extra one. Learn how the time limits split, what a voluntary level does to your other deadlines, and when to skip it.

More guides 13

After a final denial: every option left
What to check after a plan's final denial. Look at outside review, your employer, a new request, the regulator, a lawsuit, the bill, other ways to get care, and legal help.
Asking your employer to overrule a denial
If your employer pays your health claims itself, a request to the employer or its human resources team can sometimes lead to an exception. Learn how to ask, what to say, and why this is a request, not a right.
Before you appeal: corrected claims and reprocessing
When a denial comes from a paperwork mistake, a corrected claim or a reprocessing request may fix it faster than an appeal. Here is how to try that safely without losing your appeal deadline.
External review for self-funded employer plans
If your employer pays claims itself, your state's external review law generally does not apply. Learn how the federal route through private accredited reviewers works, who to call for help, and the limits.
How external review works
External review sends a denial to independent reviewers outside your plan, and their decision binds the plan. Learn which denials qualify, who runs it for your plan, the four-month deadline, timing and cost.
How to file a complaint with your state insurance department
A complaint tells your state insurance department that your insurer broke a rule. Learn when it works, who it cannot help, what to send, and why it does not replace your appeal.
How to get an expedited appeal
When waiting could seriously harm your health, you can ask for a fast appeal, decided in 72 hours or less, and ask for independent review at the same time. Here is how to ask and what your doctor can do.
How to get help from the Department of Labor
The Employee Benefits Security Administration helps people in private employer health plans. That includes self-funded plans that state insurance departments cannot help with. Here is what it does and does not do.
How to request external review
Step-by-step help to ask for an independent external review. Start by reading your final denial letter. Then send the request, add evidence and ask for a fast decision.
Keeping treatment going during an appeal
When a plan has approved ongoing care and then cuts it short, the federal rules treat that as a denial with extra protections. Learn what to ask for so care does not stop while you appeal.
Suing your health plan
What federal law says about suing a health plan over a denial, how it differs for employer plans and other coverage, and why time limits in your plan documents matter. This is information, not legal advice.
What to expect from an external review decision
How long an external review decision takes and what the notice says. Also what the plan must do if you win, and what options remain if the reviewer sides with the plan.
When the insurer misses its deadline or goes silent
If your plan does not decide your claim or appeal on time, you may be able to skip ahead to external review or court. Here is what the rule says, its small-mistake exception, and what to do in practice.

Letters, checklists and programs

Expedited appeal
How to ask your plan for a fast decision when waiting could seriously harm your health, and what to do if it says no.

Checklist
External review request
How to ask for an independent review of a final denial: the four-month deadline, which process and form apply, and the fast option.

Checklist
Internal appeal packet
What to gather, include and send when you ask your plan to reconsider a denial, and what to track after you send it.

Checklist
Appeal my Medicaid plan's cut and keep my services going
Ask your Medicaid health plan to appeal a cut or ending of a service you already get, and to keep the service going while it decides. Ask within 10 calendar days of the notice, or before the change takes effect if that is later.

Letter or script
Appeal: approved, then denied
Asks your plan to pay a claim for care it approved in advance, and to explain what changed and which plan provision lets it deny payment after approval.

Letter or script
Appeal: coding error and reprocessing
Asks your plan to reprocess a claim that was denied because of a billing or coding mistake, after your provider has corrected and resubmitted it.

Letter or script

More letters and checklists 35

Appeal: emergency care denied
Asks your plan to cover an emergency visit using the prudent layperson standard, judged on your symptoms at the time rather than the final diagnosis.

Letter or script
Appeal: ending of ongoing treatment
Asks your plan to keep covering treatment it already approved while you appeal a decision to reduce or end it, and to decide before the benefit stops.

Letter or script
Appeal: equipment or supplies
Asks your plan to cover medical equipment or supplies it denied, using your plan's own wording, your prescriber's order and how the equipment is used in your daily life.

Letter or script
Appeal: experimental or investigational
Asks your plan to reverse an experimental or investigational denial, to explain its clinical reasoning for your diagnosis, and to answer the evidence your doctor relies on.

Letter or script
Appeal: filed too late
Asks your plan to accept a claim it called late, by showing when it was first sent, quoting the plan's own filing rule, and asking it to apply any exception it contains.

Letter or script
Appeal: formulary exception
Asks your plan to cover a drug that is not on its drug list, or to lift a quantity limit, using your prescriber's reasons why the covered alternatives do not fit.

Letter or script
Appeal: level of care
Asks your plan to approve the level or setting of care your clinician recommended, such as a hospital stay or residential program, instead of a lower one.

Letter or script
Appeal: mental health or substance use care with a parity argument
Asks your plan to reverse a mental health or substance use denial and to produce its criteria and comparative analysis under the federal parity law.

Letter or script
Appeal: not a covered benefit
Asks your plan to name the exact provision it relied on and to cover care that falls within a benefit your plan document describes.

Letter or script
Appeal: not medically necessary
Asks your plan to reverse a medical necessity denial, using the plan's own standard and your records, and to have a clinician in the right field review it.

Letter or script
Appeal: out of network because no in-network option exists
Asks your plan to cover out-of-network care at the in-network level because no in-network provider could give the care in time, or at all.

Letter or script
Appeal: out-of-network allowed amount too low
Asks your plan to explain how it set the allowed amount for out-of-network care, to reprocess the claim if the method was wrong, and to pay the difference.

Letter or script
Appeal: prior authorization denied
Asks your plan to reverse a refusal of approval before care, to say what standard it applied, and to decide with a clinician in the right field.

Letter or script
Appeal: step therapy exception
Asks your plan to excuse you from trying other drugs first, using the drugs you have already tried and your prescriber's reasons, and to send its step therapy rules.

Letter or script
Ask your employer to review the denial
A polite written request to your employer's benefits office to look into a denial, name the plan administrator and send the plan documents.

Letter or script
Ask your plan to reprocess a claim under the No Surprises Act
Ask your plan to reprocess a claim with the No Surprises Act protections, so you pay only in-network cost sharing that counts toward your in-network limits, and to treat the letter as an appeal if the claim stays denied.

Letter or script
Certification of urgency (for your clinician)
A short letter in a physician's voice stating that the standard time frame could seriously harm the patient, so the plan must treat the claim or appeal as urgent and decide within 72 hours. Every clinical statement is a blank for the physician to complete.

Letter or script
Complaint to your state insurance department
Tell the state agency that regulates insurance companies what your insurer did, what you already did, and what you ask the agency to do.

Letter or script
Medicaid fair hearing request
Ask your state for a fair hearing when Medicaid denied, reduced or stopped a service. If you have a Medicaid plan, you appeal to the plan first.

Letter or script
Medicare Advantage reconsideration request
Ask your Medicare Advantage plan to review its denial again. The plan's appeal is called a reconsideration, and an outside reviewer sees the case if the plan says no.

Letter or script
Medicare redetermination request
Ask the Medicare contractor to review again a decision on your Original Medicare claim. This is the first appeal, called a redetermination.

Letter or script
No Surprises Act complaint
Tell the federal government that you were billed more than the No Surprises Act allows, using the No Surprises Help Desk or the online complaint form.

Letter or script
Peer-to-peer call brief (for your clinician)
A one-page set of notes in your clinician's voice for a call with the plan's reviewing doctor: the three points to make, the questions to ask and what to record. Every clinical statement is a blank for the clinician to complete.

Letter or script
Phone script: appeal to your Medicaid plan and keep services going
What to say when you phone your Medicaid health plan to appeal a cut or ending of services and keep them going during the appeal, what to ask for, what to do if told the provider must ask, and what to write down.

Letter or script
Phone script: ask for a peer-to-peer review
What to say to your doctor's office and your plan to ask for a call between your doctor and the plan's reviewing physician.

Letter or script
Phone script: ask for reprocessing
What to say to your plan and to the provider's billing office to get a paperwork denial corrected and the claim processed again.

Letter or script
Phone script: ask Medicare for a fast appeal when care is ending
What to say when you phone the Medicare quality reviewer to ask for a fast appeal because a hospital stay, nursing facility, rehabilitation or home health care is ending, and what to write down. For Original Medicare and Medicare Advantage.

Letter or script
Phone script: call your regulator
What to ask when you call the agency that oversees your plan, so you learn which agency is right and how to file a complaint.

Letter or script
Phone script: chase an appeal that has gone silent
What to say and ask when you have filed an appeal and heard nothing, including the federal decision deadlines for job-based and individual plans.

Letter or script
Request an expedited appeal
Asks your plan to decide an appeal as an urgent claim, within 72 hours, because waiting could seriously harm your health, and to contact your doctor.

Letter or script
Request expedited external review
Ask for a fast independent review, decided within 72 hours, when waiting could seriously harm your health.

Letter or script
Request external review
Ask for an independent review of your plan's final denial by reviewers outside the plan. The decision binds you and the plan, except where other legal remedies exist.

Letter or script
Request help from the Department of Labor
Ask the federal agency that oversees employer health plans to look at how your plan handled your claim and tell you your next steps.

Letter or script
Second-level internal appeal
Asks for a second review inside your plan after a first appeal was denied, answering the first decision's reasons and adding what is new.

Letter or script
Tell the plan it missed its deadline
A letter that tells your plan it did not decide your claim or appeal in time, quotes what the federal rule says follows, and asks the plan to confirm in writing what it did and where you now stand.

Letter or script

Programs and services 26

Run by other organizations. We summarize them and say when we last checked.

Program or service

Beneficiary and Family Centered Care Quality Improvement Organizations: find yours

The Medicare contractors that handle fast appeals when hospital or other care is ending too soon, and complaints about the quality of care. Each state is assigned to one of two organizations.

From Centers for Medicare & Medicaid Services
Program or service

California Department of Managed Health Care: Independent Medical Review

California's regulator for managed care plans reviews denials of medical services, emergency payment and experimental treatment through Independent Medical Review. One form starts either a review or a consumer complaint.

From California Department of Managed Health Care
Program or service

Center for Medicare Advocacy self-help materials

Downloadable self-help toolkits for Medicare denials involving home health care, outpatient therapy and skilled nursing facility care, from a nonprofit law organization. The page describes materials, not a helpline.

From Center for Medicare Advocacy
Program or service

Coverage Rights state-by-state appeal steps

A nonprofit website that gives each state's steps for appeal, external review and complaint when an insurer denies or delays a treatment, with a focus on medicines. No helpline or letters.

From Aimed Alliance
Program or service

Employee Benefits Security Administration help line and Ask EBSA

Free phone and online help from federal benefits advisors for people in employer health plans. They explain your rights and possible next steps, and may help you recover benefits you are owed.

From U.S. Department of Labor, Employee Benefits Security Administration
Program or service

Federal external review run for the Department of Health and Human Services

The federal independent review for some denied claims. A federal contractor, MAXIMUS Federal Services, reviews medical-judgment denials and coverage cancellations when your plan or state uses this process.

From Centers for Medicare & Medicaid Services
Program or service

Filing a Claim for Your Health Benefits (Department of Labor booklet)

A plain federal booklet on the claim and appeal rules for workplace health plans: the documents to check, how to file, the decision timeline, and your rights after a denial.

From U.S. Department of Labor, Employee Benefits Security Administration
Program or service

HealthCare.gov: how to appeal a health plan decision

The federal explanation of the two steps for a denied claim or cancelled coverage: an internal appeal with your plan, then external review by an independent third party.

From HealthCare.gov (Centers for Medicare & Medicaid Services)
Program or service

Immune Deficiency Foundation insurance appeals

Guidance on appealing a denied claim or filing a complaint, aimed at people with primary immunodeficiency, with advice on peer-to-peer review and letters of medical necessity. Condition-specific: especially immunoglobulin therapy.

From Immune Deficiency Foundation
Program or service

Indian Health Service Purchased/Referred Care: appeal a denial

How American Indian and Alaska Native patients ask the Indian Health Service to reconsider a denial of payment for care received away from an Indian Health Service or tribal facility.

From Indian Health Service
Program or service

KFF Health News: seven tips for fighting a health insurance denial

A news article with seven tips for fighting a prior authorization denial, including knowing your plan type, working with your provider, staying organized, and asking for help. Written by a reporter, not by an agency.

From KFF Health News
Program or service

Maryland Insurance Administration: appeals and grievances

Maryland's insurance regulator explains the state appeals and grievances law: you first use your plan's own grievance process, then you can ask the Insurance Administration to review a denial of medically necessary treatment.

From Maryland Insurance Administration
Program or service

Massachusetts Office of Patient Protection: external review

Massachusetts runs independent review of health plan decisions based on medical necessity. You have 4 months from your plan's final denial letter to ask, and an eligible request gets a final and binding decision.

From Massachusetts Health Policy Commission, Office of Patient Protection
Program or service

Medicaid fair hearings: federal explainer

A federal fact sheet on the right to a Medicaid fair hearing when a state denies, reduces or ends your Medicaid benefits, with hearing rights, deadlines that vary by state, and how benefits can continue.

From Centers for Medicare & Medicaid Services, Medicaid.gov
Program or service

Medicare Beneficiary Ombudsman

A federal office that helps with Medicare complaints and information requests that your plan or 1-800-MEDICARE has not resolved. You reach it by asking a 1-800-MEDICARE representative to send it on.

From Centers for Medicare & Medicaid Services
Program or service

Medicare Interactive: Medicare appeals

Free plain-language guides to appealing a Medicare denial, split by Original Medicare, Medicare Advantage and Part D drug coverage, from the Medicare Rights Center. Covers Medicare only.

From Medicare Rights Center
Program or service

Medicare.gov: filing an appeal

The official Medicare page on appealing a coverage or payment decision, with separate instructions for Original Medicare, Medicare health plans and drug plans, plus fast appeals when services end too soon.

From Medicare.gov (Centers for Medicare & Medicaid Services)
Program or service

National Association of Insurance Commissioners: find your state insurance department

A national directory where you pick your state or territory to find its insurance department, get contact details and start a complaint. Useful for plans bought from an insurance company.

From National Association of Insurance Commissioners
Program or service

New York Department of Financial Services: external appeal

If a New York insurer or health maintenance organization denies care as not medically necessary, experimental or out of network, you can ask the state for an external appeal. You have 4 months from the plan's final decision.

From New York State Department of Financial Services
Program or service

Office of Personnel Management: disputed claims for federal employee health plans

The Office of Personnel Management (OPM) reviews a denied claim from a federal employee health plan after the plan has reconsidered it. This page explains the order, how to write to OPM, and the response times it states.

From U.S. Office of Personnel Management
Program or service

Smart NC: health claim denied (North Carolina)

A North Carolina Department of Insurance program that helps consumers resolve coverage disputes with their health insurance company. The page says there is no cost for its services.

From North Carolina Department of Insurance, Smart NC
Program or service

Texas Department of Insurance: appeal, external review and complaints

The Texas Department of Insurance explains how to appeal a denied treatment, ask for an independent external review and file a complaint. It helps with fully insured plans and cannot overturn a reviewer's decision.

From Texas Department of Insurance
Program or service

Triage Cancer state-by-state health insurance appeals toolkit

Free downloadable toolkit with general appeals guidance plus a section and forms for each state. Made by a cancer-focused legal-education nonprofit, but the page describes it as for people using health insurance and challenging denials.

From Triage Cancer
Program or service

TRICARE appeals

The official TRICARE page on the four kinds of appeal (factual, medical necessity, pharmacy, and Medicare-TRICARE), with mailing addresses for each regional contractor and the Defense Health Agency.

From TRICARE (Defense Health Agency)
Program or service

Veterans Affairs clinical appeals and decision reviews

How a veteran asks Veterans Affairs (VA) to review a treatment decision (a clinical appeal) or a decision about a VA benefit, including health care benefits, with the review options and what to send.

From U.S. Department of Veterans Affairs
Program or service

Veterans Affairs patient advocate program

Every VA medical facility has a patient advocate who handles concerns from veterans and families. The advocate can help with a care problem and, if needed, help you file an appeal.

From U.S. Department of Veterans Affairs, Veterans Health Administration

Your next step may connect

Your coverage
The appeal steps, deadlines and regulators for your kind of plan, from employer plans to Medicare and Medicaid.
Bills and help
Keep the bill from getting worse while you appeal, and find a person who can help, often for free.