105 guides
All guides
Plain-language guides, grouped by the six areas of the site.
Understand your denial
Work out what was refused, why, which rules apply to you, and by when you must act. 16
Everything in Understand your denial
- Appeal deadlines by coverage type
A table of the first appeal deadline and the next level. It covers job-based, Marketplace, Medicare, Medicaid, TRICARE, Veterans Affairs and other coverage. Each is counted from a stated date.
- Appeal, complaint, grievance and external review: the difference
Five words that sound alike, and what each one means. They cover asking the plan to look again, asking an outside reviewer, complaining to a regulator, and filing a grievance.
- Denied, rejected, or just your share of the cost
Three things that look alike on a statement or a bill: a denial, a rejected claim and your normal share of the cost. Learn how to tell them apart and who has to act.
- How deadlines are counted, and what to do if you missed one
How to tell which date your deadline counts from. Learn what an "at least" minimum means, how weekends are handled where the rules say, and what to try if a deadline has passed.
- How to find out what kind of plan you have
Use your card, your denial letter and a few questions to find out which kind of health coverage you have. Every deadline and appeal step depends on it.
- How to read a denial letter line by line
Find the reason, the rule the plan relied on, your appeal rights and your deadline in a denial letter. Read them in the order that makes the letter easiest to act on.
- How to read an Explanation of Benefits
What the lines on an Explanation of Benefits mean, how to tell what you owe from what was refused, and why you should not pay from it alone.
- Is it worth appealing: what the numbers say
What published figures show about how often appeals change denials. The numbers from different programs cannot be compared. Here is how to decide for your own case.
- Self-funded or fully insured: how to tell and why it matters
Four ways to find out if your employer plan pays claims itself or buys insurance. This changes who regulates it and how you get an outside review.
- The first 48 hours after a denial
A calm list of what to do, and what to hold off on, in the first two days after a health plan says no to care, a drug or a claim.
- The kinds of no: claim denial, prior authorization, pharmacy rejection, coverage ended
Six different ways a plan can say no, where each one shows up, and which clock and rules go with it, so you know what you are actually holding.
- The three families of denial reason
Almost every denial reason falls into one of three families: paperwork, coverage or clinical. Knowing which one you have tells you who acts first and what evidence helps.
- What a denial letter must tell you
A federal rule lists what a denial notice from an employer plan or an insurance company must contain. Here is the exact list, and what to do when something is missing.
- Who regulates your plan
Which agency oversees each kind of health coverage, and where to send a complaint. A state insurance department cannot help with every plan.
- Whose job is it to fix this
Work out who must act first on a denial: you, your provider, the plan, or you and your provider together. Then learn how to get the right person moving.
- Your rights when a health plan says no
The main rights federal rules give you after a denial, in plain words, with the limits. See what a private plan must do and what Medicare, Medicaid and other programs add or change.
Build your case
Collect the file, the records, your doctor's support and the plan's own rules, then write it up. 16
- How to ask for an itemized bill and check it
Ask the provider for every charge on your account, then compare it with your Explanation of Benefits to find errors. Covers the billing-records right you do have and the itemized-bill right the federal rules do not give.
- How to ask your doctor for a letter of medical necessity
Make it easy for your doctor's office to write a letter that answers the plan's reason for denying your care. Covers who to ask, what to hand over, when, and what to do if the office says no.
- How to assemble and send an appeal packet
Put your appeal letter, your doctor's letter, records and plan documents in order, then send the packet so you can prove the plan received it. Includes a check of what to enclose and what to keep.
- How to find clinical guidelines and studies
Work with your doctor to find the guidelines and studies that back your treatment, and use them to answer the plan's reason. Covers experimental denials, past review decisions and how to cite evidence.
- How to find the insurer's medical policy for your treatment
Ask for the clinical rule your plan used to deny your care, find out which version applied, and check it against your records. Covers what a denial notice must say and what you can request for free.
- How to get your medical records
Ask your doctor, hospital or clinic in writing for a copy of your own records for your appeal. Covers what the federal health privacy rule says about timing and fees, and which records an appeal needs.
- How to get your plan documents
Ask your plan administrator in writing for the summary plan description and the documents that set your plan's rules, so you can check the denial against them. Covers who to write to, cost and timing.
- How to keep a call log and paper trail
Record every call, letter and message with your plan and providers, with names, dates and reference numbers, so you can prove what was said and keep your deadlines straight. Includes a simple log you can copy.
- How to read your claim file
Go through the file your plan sends. Find what it relied on, who reviewed your claim, what it missed and whether it kept to its own deadlines. Then your appeal can answer the real reason.
- How to request your claim file
Ask your plan in writing, before you appeal, for everything it used to decide your claim. Covers what to ask for, where to send it, what the rules say about cost and timing, and what to do if the plan stalls.
- How to talk to your insurer on the phone
Call habits that protect you, such as getting names and reference numbers and asking for it in writing, and what a phone call can and cannot do. Links to phone scripts for common calls after a denial.
- How to write an appeal letter that works
A plain structure for your appeal letter, from what you want to a request for a written decision. Includes what to put in each part, what to leave out, and links to letters for each denial reason.
- Peer-to-peer review and how to prepare your doctor
A peer-to-peer review is a phone call between your doctor and the plan's reviewing doctor. It is usually worth asking for early, but availability and timing vary by plan. Here is how to ask and prepare.
- Using your plan's own words
Quote the plan's own definitions, exclusions and criteria back to it in your appeal. Covers where to find them, how to quote them accurately, and what to do when the plan's documents work against you.
- What a strong letter of medical necessity contains
A checklist for the letter your doctor writes, so it answers the plan's stated reason, uses the plan's own criteria, and gives the reviewer the facts needed to decide. For you to check the draft against.
- Writing your personal statement
How to write a short, honest account of what your condition and the denial have done to your health and daily life, to sit beside your doctor's letter in an appeal. Includes prompts and what to leave out.
Appeal
File the appeal, get a fast decision when health is at risk, and take it outside the plan if it says no again. 16
- 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 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.
- 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.
- 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.
- 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.
- 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.
Your coverage
The appeal steps, deadlines and regulators for your kind of plan, from employer plans to Medicare and Medicaid. 19
- Children's Health Insurance Program appeals
Your child's separate Children's Health Insurance Program plan denied something. Ask for an independent review, not a Medicaid fair hearing. Here is what the federal rules do and do not promise.
- Employer plans: the complete appeal path
The whole path for a denial from a job or union plan. It runs from the plan's appeal to independent review, the agency to call, and the court option.
- Fast appeals when a hospital or facility is ending your care
A hospital says you are being discharged, or a nursing facility, home health agency, rehabilitation facility or hospice says Medicare coverage is ending. You can ask for a fast review. Time of day matters.
- Federal employee plan appeals
How to appeal a Federal Employees Health Benefits plan denial. Ask the carrier to reconsider within 6 months. Then ask the Office of Personnel Management to review. We also explain what a lawsuit looks like.
- Fully insured employer plans and state protections
If your employer buys insurance for you, both federal law and your state's insurance rules apply. Here is what that adds, who to call, and how to find out which kind of plan you have.
- Government and church employer plans
Plans run by state and local governments, school districts and churches are outside much of ERISA. Learn which federal rules still protect you, which do not, and who to ask.
- Marketplace and individual plans: the appeal path
How to appeal a denial from a plan you bought yourself. It may be through HealthCare.gov, a state marketplace or an insurer directly. You appeal to the plan, then to independent review.
- Marketplace eligibility appeals are not claim appeals
A Marketplace appeal challenges a decision about your eligibility or tax credit. It cannot overturn an insurer's claim denial. Learn what it covers, the 90-day deadline, and what to do for a claim denial instead.
- Medicaid appeals and fair hearings
How to challenge a Medicaid denial, cut or ending of benefits in a state fair hearing. Learn what notice you must get, how to keep benefits going, and why your state's deadline matters most.
- Medicaid managed care: the plan appeal comes first
If a Medicaid health plan denies or cuts a service, you appeal to the plan within 60 days. Only after that can you ask the state for a fair hearing. Here is the order and how to keep benefits going.
- Medicare Advantage appeals
How to appeal when a Medicare Advantage plan refuses to approve or pay for care. Learn the 65-day deadline, the plan's decision times (including the 2026 prior authorization rule) and the automatic outside review.
- Medicare drug plan appeals and exceptions
What to do when a Medicare drug plan will not cover a prescription. Ask for a coverage decision or an exception, then appeal. The outside review step is not automatic.
- Medicare observation status
If a hospital admitted you and then changed you to observation, you may have a right to appeal that change, but only before you leave the hospital. Learn who qualifies, what notice to expect and what has closed.
- Original Medicare: the five appeal levels
A plain walk through the five levels of a Medicare Parts A and B appeal. It starts from the Medicare Summary Notice. It names the deadlines that trip people up and what to do first.
- Student, short-term and other coverage with fewer rights
Student plans, short-term plans, sharing ministries and fixed indemnity products carry different appeal rights. Learn which federal protections apply, which do not, and where to start when a claim is denied.
- TRICARE appeals
How to appeal a TRICARE denial. Start with a written reconsideration within 90 days. Next steps differ for factual and medical necessity denials, with dollar minimums at the later levels.
- Two plans at once and COBRA
A short guide to claims stuck between two health plans and to continuation coverage after a job change. It explains what this site can and cannot confirm, and who to ask.
- Veterans Affairs health care and community care denials
Veterans Affairs uses two different routes for health care disputes: a clinical appeal for treatment decisions and a decision review for benefit and payment decisions. Pick the right one first.
- What a Medicaid fair hearing is like
A calm walk through a Medicaid fair hearing. Learn how to prepare, what happens on the day, and what the agency's lawyer does. Know the rights federal rules give you.
What was denied
The playbook for your kind of denial: prior authorization, drugs, out-of-network care, mental health, treatments, billing. 22
- Ambulance bills
Air ambulance bills are covered by the federal No Surprises Act. Ground ambulance bills are not. Here is what to do about an ambulance bill or a denied ambulance claim.
- Approved, then denied
What to do when your plan approved a service or said it was covered, then refused to pay the claim. Includes what Medicare Advantage plans may not do.
- Coding and billing errors
How to tell if a denial comes from a coding or billing mistake. Learn who must fix it, how to get the codes, correct the claim and ask the plan to reprocess it.
- Drug not covered: formulary exceptions
How to ask your plan to cover a drug that is not on its formulary. See who supplies the medical reasons and the Medicare drug plan deadlines.
- Emergency room claim denied
What to do when your plan denies or reduces an emergency room claim. Learn the prudent layperson standard and why a plan cannot require prior approval for emergency care.
- Equipment, home health and therapy limits
What to do when a plan denies medical equipment, home health care or therapy visits, or says you used up a visit limit. Also what Medicare says about care that maintains your condition.
- Experimental or investigational
Your plan says a treatment is experimental, investigational or unproven. Learn how to use the plan's own definition and how to bring evidence and your doctor's judgment.
- Hospital stay denials
A plan may deny a hospital admission, cut a stay short, or call you an outpatient under observation. Here is what to do, including Medicare's fast appeal for discharges and the childbirth stay rule.
- Level-of-care denials
Your plan says you no longer need the level of mental health or substance use care you are in, such as residential or inpatient treatment. Here is how to keep care going while you appeal.
- Mental health and substance use denials: using the parity law
How to use the federal parity law when appealing a mental health or substance use denial. Learn which documents to demand and what is and is not being enforced as of 11 November 2026.
- Not a covered benefit
What to do when a plan says a service is not a covered benefit or is excluded. Check the plan document and the law, and see which arguments can still work.
- Not medically necessary
What "not medically necessary" means on a denial. See what the plan must show you, how to build an appeal with your doctor, and when independent external review applies.
- Out-of-network denials and network gap exceptions
What to do when your plan denies or underpays care because the provider is out of network. Learn about network gap exceptions, continuity of care and the cases federal law protects.
- Out-of-network underpayment
Your plan paid an out-of-network claim but far less than the provider charged. Learn how plans set the allowed amount and how to use price benchmarks in a dispute.
- Preventing the next denial
Steps to take before, during and after care. They make a denial less likely and an appeal stronger. Get approvals in writing, confirm network status and keep records.
- Prior authorization denied
What to do when your plan refuses to approve a service before you get it. Also which decision deadlines apply to employer, Marketplace, Medicare Advantage and Medicaid plans.
- Prior authorization stuck
What to do when your plan has not answered a prior authorization request, how long each type of plan has, and how to push a stalled request forward.
- Quantity limits, tier exceptions and forced switches
What to do when your plan limits how much of a drug you can get, charges a high tier price, or tells you to switch drugs. Also what Medicare drug plans must do.
- Step therapy exceptions
How to ask your plan to skip the "try this drug first" rule. See what a step therapy exception request must show, and where state rules and Medicare drug plan deadlines fit.
- Surprise bills and the No Surprises Act
Who the federal No Surprises Act protects, which out-of-network bills it bars, which it does not, and how to complain to the No Surprises Help Desk.
- Timely filing, coordination of benefits and eligibility denials
What to do when a claim is denied as filed too late, because another insurer pays first, or because the plan says you were not covered. See who has to fix each one.
- When coverage is cancelled retroactively
What federal rules say about a plan cancelling your coverage back in time. A rescission is different from a cancellation for unpaid premiums. Here is how to appeal.
Bills and help
Keep the bill from getting worse while you appeal, and find a person who can help, often for free. 16
- A bill is not an Explanation of Benefits: do not pay yet
A provider's bill and your plan's Explanation of Benefits are different papers. Match them before you pay, ask for a hold in writing, and do not pay what your plan may owe.
- Acting for someone else
You can usually help a parent, partner or adult child with a denial if they give written permission. Here is how to name a representative with plans, Medicare and Medicaid, and what this page does not cover.
- For clinicians' offices: supporting a patient's appeal
A short guide for doctors and office staff. Learn when to ask for a peer-to-peer call, which letters to write, how to certify urgency, and what the patient needs to file their own appeal.
- Good faith estimates for people paying themselves
If you have no insurance, or choose not to use it, you are entitled to a good faith estimate. If the bill comes in $400 or more over it, you may be able to dispute the bill.
- Help with drug costs
Two different problems get mixed up: your plan will not cover a drug, or you cannot afford your share. Fix the first with an exception or appeal, and look at nonprofit directories for the second.
- Hospital financial assistance
Many hospitals will reduce or cancel a bill for people who cannot afford it, whatever your insurance appeal decides. Here is how to find the policy, apply, and keep your deadline.
- How to negotiate a medical bill
You can ask a provider to lower a bill. This page shows the order that works best: check the bill, ask for financial assistance, then make a written offer and get the agreement in writing.
- Legal aid and when to hire a lawyer
Free legal aid helps some people with health coverage, Medicaid and medical debt. A lawyer matters most for a hearing, a lawsuit against a plan, or a debt lawsuit. Here is how to find one and what to ask.
- Medical debt and your credit report
Unpaid medical bills can end up on credit reports. Here is how to check your reports, dispute mistakes in writing, and where to confirm today's rules, which are set by federal and state law.
- Medical debt in collections
A medical bill in collections can still be questioned. Confirm it is real and yours, check it against your insurance paperwork, answer in writing, and see what help is still open.
- Medicare counseling through the State Health Insurance Assistance Program
Every state has a free Medicare counseling program that is not tied to any insurance company. Here is what it does, how to reach it, and when to call 1-800-MEDICARE or a quality improvement organization instead.
- Paying for an advocate or an artificial intelligence appeal service: what to ask
Paid advocates, artificial intelligence appeal services and lawyers do different jobs. Check free options first, then ask who does the work, what they need, how they use your data and how they measure results.
- Payment plans and medical credit cards
A payment plan spreads a bill out but does not make it smaller. Here are the questions to ask a provider, or a lender that offers a medical credit card or loan, before you sign anything.
- The bill while you appeal
Appeals take months and the bill keeps coming. Ask the provider for a hold in writing, check the bill against your Explanation of Benefits, and do not pay what your plan may still owe.
- What a state consumer advocate does
Some states run or fund free consumer advocates who explain your plan, write appeals and push back on insurers. Here is what three of them do, and how to find out what your state offers.
- Where to get free help, by coverage type
The right free helper depends on who regulates your plan. Here is a map from job-based, Marketplace, Medicare, Medicaid and military coverage to the people who can help at no cost.
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