Denied a health insurance claim or had your coverage canceled? You’re not alone — but you’re not powerless either. Knowing how to appeal an insurance company decision gives you a chance to overturn denials and take control of your care.
This guide breaks down both internal and external appeal processes, outlines your rights, and offers expert tips to help you get started.
Visit the Education Center for more resources on navigating health insurance, billing errors, and patient advocacy.
What Is an Insurance Appeal?
When your health insurance plan refuses to cover a service or ends your policy, you have the right to appeal. This means you can ask the insurer to review and reconsider their decision. You also have the right to an independent third-party review — so the final say isn’t just in the hands of the insurance company.
Types of Health Insurance Appeals
Internal Appeal
This is the first step in challenging a denial. You’re asking your insurance company to take a second look at their decision.
There are three stages:
File a claim – typically submitted by you or your provider.
Receive denial notice – the insurer must explain why they rejected it.
Within 15 days (prior authorization)
Within 30 days (services already received)
Within 72 hours (urgent cases)
Submit internal appeal – include all required forms and any supporting documentation (like a letter from your doctor). You must file within 180 days of denial.
If you have an urgent health situation, you can skip ahead to an external review while the internal appeal is still ongoing.
External Review
If the internal appeal fails, you can request an external review. This is conducted by an independent, third-party reviewer who has no stake in your case. They can overturn the insurer’s denial — and their decision is final.
You must request this review within 4 months of your final internal appeal denial. Depending on your state, this process may be overseen by your state’s Department of Insurance or the federal government (CMS).
Common reasons for external review include:
Medical judgment disagreements
Denial of experimental or investigational treatments
Coverage cancellation based on false info (as claimed by insurer)
What You’ll Need for Your Appeal
Keep detailed records and copies of all documentation:
Explanation of Benefits (EOB)
Denial letters
Appeal request forms
Doctor’s notes or letters supporting your claim
Notes from phone calls with insurers (include names, titles, and call summaries)
Always send copies — keep your originals.
If Your Care Is Urgent
In medical emergencies, you can request an expedited internal and/or external review. This speeds up the process if waiting could jeopardize your life or health. Decisions must be made within 4 business days, followed by a written notice within 48 hours.
How Long Does an Appeal Take?
Internal appeal:
30 days (for future services)
60 days (for past services)
External review:
45 days (standard)
72 hours (expedited)
Cost to File an Appeal
Federal reviews through CMS (HHS) are free of charge. If your insurer uses a third-party review organization, the most you could be charged is $25.
Need Help with the Process?
Your state’s Consumer Assistance Program (CAP) or Department of Insurance may help with filing an appeal. You can also visit:
Call: 1-888-866-6205
Email: [email protected]
Fax: 1-888-866-6190
Conclusion
Filing an appeal after a denied insurance claim may feel overwhelming — but it’s a right worth using. Many denials are reversed when challenged properly. By understanding how to appeal an insurance company decision, gathering the correct documents, and staying organized, you can give yourself the best shot at getting the coverage you need.
Need more help? Return to the Education Center for step-by-step guides on understanding your bill, spotting errors, and finding a patient advocate.
