How to Appeal a Health Insurance Denial
A denial is not the final word. This guide walks you through the steps that work for any plan — then exactly how the process runs for your specific type of coverage.
Appealing works more often than people think
The steps that work for any plan
No matter what coverage you have, a strong appeal follows the same path. Start here, then jump to your plan type below for the specific deadlines and levels.
- Read the denial notice and find two things: the reason and the deadline. Insurers must tell you why they said no and how to appeal. Common reasons include "not medically necessary," "experimental," out-of-network, or a missing prior authorization. For 2026, Medicare Advantage plans must now name the specific clinical criterion you allegedly didn't meet — so you can answer it directly.
- Get your records and your plan's rules. Request your full claim file and the plan's written coverage policy for the service. Think of an appeal as a contract dispute: your plan document defines what's covered, and you're showing your situation fits.
- Ask your doctor for a letter of medical necessity. This is your single most powerful document. It should explain your diagnosis, what was tried before, why this specific care is needed, and — when relevant — directly rebut the plan's stated reason, citing your records and medical guidelines.
- Write a clear, organized appeal. State what you want approved, why the denial was wrong, and what you're attaching (doctor's letter, records, relevant medical literature). Keep it factual and firm. Many organizations offer free templates — see the help section below.
- Submit on time and keep proof of everything. Note submission dates, names of everyone you speak with, and confirmation numbers. Send anything important in a way you can track. Keep copies of it all.
- Ask for a fast ("expedited") review if waiting could harm you. If a standard timeline would seriously jeopardize your health or ability to function, you (or your doctor) can request an expedited appeal — decisions generally come within 72 hours.
- If you lose, go to the next level — especially independent review. Almost every plan offers more than one level of appeal, ending in a review by someone outside your insurer. That independent step is where many denials finally fall. Don't stop at the first "no."
You're not on your own
Take it one step at a time — and take the steps with you. Get the free one-page Appeal Game Plan to print and keep.
First, know what kind of plan you have
This is the step most people skip — and it determines everything: who reviews your appeal, how long you have to file, and who to call for help. Check your insurance card, your benefits paperwork, or ask your plan or your employer's HR department. Your coverage falls into one of these buckets:
- A Marketplace or individual plan you bought yourself — through HealthCare.gov, a state exchange, or directly from an insurer.
- A job-based (employer) plan — and within this, whether it's self-funded (your employer pays the claims) or fully insured (your employer buys coverage from an insurer). This one distinction changes your appeal rights. A large employer is likely self-funded; a small employer is usually fully insured. HR can confirm.
- Medicare Advantage (Part C) — Medicare run by a private plan.
- Original Medicare (Parts A & B) — coverage directly through the federal government.
- A Medicare Part D prescription drug plan.
- Medicaid or CHIP — including state Medicaid managed-care plans.
Not sure? Your state Department of Insurance or a free counseling service (below) can help you identify your plan in minutes.
Who this is for: You bought your plan through HealthCare.gov, a state Marketplace, or directly from an insurer. Most fully insured job-based plans follow these same rules.
Under the Affordable Care Act, you have two guaranteed layers of appeal:
- Internal appeal — ask your insurer to fully review its decision. File within 180 days of the denial.
- External review — an independent third party (not your insurer) makes a binding decision, run by your state or a federal process. Standard decision within 45 days; urgent within 72 hours.
If your situation is urgent, you can request the external review at the same time as the internal appeal. Your final internal denial letter must explain how to start it.
Who this is for: You get coverage through work. First find out whether your plan is self-funded or fully insured — HR can tell you, and it changes who oversees your appeal.
Self-funded plans (your employer pays the claims) are governed by the federal ERISA law and the U.S. Department of Labor:
- At least 180 days to file your appeal.
- You can request your entire claim file for free — internal guidelines, the reviewer's qualifications, and notes on your case. Appeals often succeed after this reveals an error.
- A federal external review after the internal appeal, and the right to go to federal court.
Fully insured plans (your employer buys coverage from an insurer) follow the ACA framework — internal appeal, then a state external review — and your state Department of Insurance can help.
Who this is for: You get Medicare through a private plan. Appeals run through five levels:
- Plan reconsideration — send a letter plus your doctor's support. File within 60 days. Decision in about 30 days (for a service) or 60 days (for payment).
- Independent Review Entity — if the plan upholds the denial, it's automatically forwarded to an outside reviewer.
- Administrative Law Judge. 2026: at least $200 in dispute.
- Medicare Appeals Council.
- Federal court. 2026: at least $1,960 in dispute.
2026 tip: Plans must now state the specific clinical criterion they say you didn't meet. Quote it, and have your doctor rebut it point by point.
Who this is for: You have Medicare directly through the federal government. You'll usually see a denial on your quarterly Medicare Summary Notice.
- Redetermination by the Medicare contractor. File within 120 days of your Medicare Summary Notice.
- Reconsideration by a Qualified Independent Contractor. File within 180 days.
- Administrative Law Judge. 2026: at least $200 in dispute.
- Medicare Appeals Council.
- Federal court. 2026: at least $1,960.
If you're told covered services are ending too soon (a hospital stay, home health), you have a separate fast appeal — act immediately; the deadline is very short.
Who this is for: Your Medicare drug plan won't cover a medication, puts it on a high cost tier, or requires you to try something else first.
Start by asking your plan for a coverage determination or an exception — your prescriber's supporting statement is essential. If that's denied:
- Redetermination by your plan. File within 60 days. Decision: 7 days standard / 72 hours fast.
- Independent Review Entity — an outside reviewer.
- Administrative Law Judge. 2026: at least $200 in dispute.
- Medicare Appeals Council, then Federal court.
Who this is for: You have Medicaid or CHIP, including a state managed-care plan. Exact deadlines vary by state — your notice is the authority — but the structure is consistent.
- Plan (internal) appeal — in managed care you must complete this first. Generally file within 60 days of the notice.
- State Fair Hearing — an impartial hearing before the state. Deadline varies (often 90–120 days); decision in about 90 days.
Protect your current care: if a service you already receive is being reduced or stopped, you can usually keep it during your appeal — but only if you ask in time, typically within 10 days of the notice or before the change takes effect. Request "continuation of benefits."
Don't skip the internal appeal. Jumping straight to a State Fair Hearing can get your request dismissed.
Get Your Free Appeal Game Plan
When to ask for a fast ("expedited") appeal
Every plan type offers a faster track when time matters. Request an expedited appeal if waiting for a standard decision could seriously jeopardize your life, your health, or your ability to regain maximum function. In most cases:
- A decision must come within about 72 hours.
- You or your doctor can request it — and a doctor's statement that the delay is dangerous carries real weight.
- Say it plainly in your request: that the standard timeline poses a risk to your health.
HealthCare.gov – Appeals
Internal appeal and external review steps for Marketplace and individual plans.
Medicare.gov – Appeals
Official appeal steps for Original Medicare, Medicare Advantage, and Part D. Call 1-800-MEDICARE.
U.S. Department of Labor – EBSA
Free benefits advisors for job-based (self-funded/ERISA) plans.
Call 1-866-444-3272.
Medicaid.gov
Find your state Medicaid agency and its Fair Hearing process.
Free one-on-one support
SHIP (State Health Insurance Assistance Program)
Free, unbiased Medicare counseling in every state — including help with appeals.
Call 1-877-839-2675
Medicare Rights Center
National helpline for Medicare questions and denials, in English and Spanish.
Call 1-800-333-4114
Patient Advocate Foundation
Free case management for people with serious illness, plus a guide to writing your appeal.
Triage Cancer
Free, plain-language appeal tools and a questionnaire to identify your plan type — useful for everyone, not just cancer patients.
Your State Department of Insurance
Free consumer help and external review for state-regulated plans. Find yours through the NAIC directory.
Center for Medicare Advocacy
Guides and assistance on Medicare coverage and appeals.
It depends on your plan. Marketplace and most employer (ERISA) plans give you at least 180 days; Original Medicare gives 120 days from your Medicare Summary Notice; Medicare Advantage and Part D give 60 days; Medicaid is generally 60 days for the internal appeal. Your denial notice states your exact deadline — treat it as the authority and act quickly.
No. Most appeals are filed by patients and their doctors without a lawyer. Free counselors — SHIP, the Patient Advocate Foundation, your State Department of Insurance — can guide you. Legal help becomes more relevant only at the higher court levels.
A letter of medical necessity from your doctor that directly answers the plan's stated reason for the denial, supported by your medical records and recognized medical guidelines.
A review by qualified people who don't work for your insurer. Their decision is binding on the plan, which is why independent review overturns so many denials. Most plans offer it after you complete the internal appeal.
Often yes, especially in Medicaid: if you appeal in time (typically within 10 days of the notice or before the change takes effect), your current services can continue while your appeal is decided. Ask for "continuation of benefits" when you file.
Yes. A large share of appealed denials are overturned, and most denials are never appealed at all. The deadline is the real risk — not the effort.