Handle denials and appeals · Lesson 4 of 16
How do I prepare an appeal?
The short answer
An appeal asks your plan to review a denial. Read the notice for the reason and deadline. Gather records that answer that reason, often with a letter from your clinician. Send it as the notice says, and keep copies. If the plan still says no, outside review may be available.
Key takeaways
- Your notice lists the deadline. Many plans allow 180 days for an internal appeal.
- The strongest appeals respond directly to the reason for the denial.
- If waiting could seriously harm your health, ask for an urgent (expedited) review.
1. Read the notice
The denial notice should explain the reason and how to appeal.[1] Write down the deadline, the address or portal, and the claim number. You can ask the plan for the documents and rules it used to decide.
2. Check the deadline
For most private and Marketplace plans, you have 180 days from the notice to file an internal appeal.[2] Employer plans covered by federal law must give at least 180 days.[1] Medicare and Medicaid use different timelines. Always use the date on your own notice.
3. Gather evidence
Match your evidence to the reason:
- Not medically necessary: a letter from your clinician explaining why you need the care, plus records and test results.
- Not covered: the part of your plan document that you believe covers it.
- Coding or paperwork: ask the provider to correct the claim first. That may solve it without an appeal.
4. Write a short letter
Include your name, plan ID, claim number, the service, and a few sentences on why you believe the plan should pay. Be factual and brief. Attach your evidence.
5. Send it and keep records
Use the method on the notice. Keep copies, and note dates and names from every call.
If you are still denied
For many plans, you can then ask for an external review by an independent reviewer.[2] If your care is urgent, you can ask for an expedited review, and sometimes request external review at the same time.[2]
An appeal does not guarantee approval. A clear, complete appeal gives the reviewer what they need to decide.
What can be different for you
Urgent pre-service appeals under employer plans must be decided within 72 hours.[1] Medicare has five appeal levels and its own forms. Medicaid appeals include a state fair hearing. Some states run external review for state-regulated plans. Self-funded employer plans may use a federal process.
More detail (optional)
Asking for your claim file
Under many plans you can ask, free of charge, for copies of documents related to your claim, including the rules or guidelines used.[1] This helps you see what the reviewer saw.
Getting help
A state consumer assistance program, a SHIP counselor for Medicare, or a patient advocate can help you prepare. See "Who can help me navigate this?"
Words in this lesson
- Appeal
- A formal request asking your plan to review and change a decision, such as a denied claim or prior authorization.
- External review
- A review of your plan's decision by an independent organization, usually after an internal appeal.
- Expedited (urgent) appeal
- A faster review when waiting for a standard decision could seriously harm your health.
- Medically necessary
- Care your plan agrees is needed to diagnose or treat a health condition, based on its rules. Plans may deny care they consider not medically necessary.
Related
Where can I go for help?
Free help is often close by: the member services number on your insurance card, the billing office for your provider, your state insurance department, and nonprofit patient advocates.
This is general education. For decisions about your own plan, taxes, or legal rights, check your plan documents or a qualified professional.