Appeal
Complain to a regulator
Tell the agency that oversees your plan what it did wrong, and know what the agency can and cannot do.
Do this today
- Use the tool: Find help near you Pick your state and coverage and see the regulator, the free consumer program and the Medicare counselors for you.
- Read: How to file a complaint with your state insurance department 5 minute read. 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.
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Put this step on My Plan
So you can come back to it, and keep your dates and calls in one place.
In brief
- A state insurance department oversees insurance companies and their policies. It generally cannot help with a self-funded employer plan, because state insurance law cannot be applied to it.
- A complaint does not stop your appeal deadline. File the appeal or the external review request first or at the same time.
- In some states the same office also takes external review requests. Check your state page.
Read the full guide: How to file a complaint with your state insurance department
More guides, tools and letters
More guides, tools, letters 20
Guides
- 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 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.
Tools
- Tool
Find help near you
Pick your state and coverage and see the regulator, the free consumer program and the Medicare counselors for you.
- Tool
Regulator complaint builder
Find the agency that oversees your plan and draft a short, factual complaint.
Letters and scripts
- 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
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
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
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.
Programs and services
- 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
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
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
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
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
No Surprises Help Desk: surprise bill questions and complaints
The federal help desk for questions or complaints that a plan, provider or facility broke the surprise billing rules. It reviews the complaint and may refer it to another federal or state enforcer.
From Centers for Medicare & Medicaid 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
Washington Insurance Commissioner: appealing a health insurance denial
Washington's insurance regulator explains how to appeal a denial, which plans it regulates, and where to find sample appeal letters by denial reason. Consumer advocates answer questions and take complaints.
From Washington State Office of the Insurance Commissioner
Questions to keep handy
- What exactly was denied, and under which part of the plan?
- What is my deadline, and what is it counted from?
- Where and how do I send my request, and how will I prove it arrived?
- Who decides, and can I ask for a faster decision?
Not what you need? Find a person who can help, or search the whole site.