Federal agency ยท HealthCare.gov (Centers for Medicare & Medicaid Services)
HealthCare.gov: how to appeal a health plan decision
The federal explanation of the two steps for a denied claim or cancelled coverage: an internal appeal with your plan, then external review by an independent third party.
Know before you go
This page is free information, not a place to file. It explains your right to an internal appeal and to external review of a denied claim or cancelled coverage. A separate notice on the page points to appeals about Marketplace eligibility (for example, whether you qualify for savings); that is a different process and does not cover a denied medical claim. Your denial notice, not this page, gives your plan's deadlines and addresses.
- Cost
- Not stated. The page is free to read and does not state a fee for appealing.
- Where
- Nationwide
- How to start
- Read the page, then use the links from it to the internal appeal and external review pages. File your internal appeal with your plan, using the address and deadline on your denial notice.
- Have ready
- Your denial notice; Your plan name and member number; Any explanation of benefits for the claim
Where this comes from
- Provider
- HealthCare.gov (Centers for Medicare & Medicaid Services)
- Source we read
- https://www.healthcare.gov/appeal-insurance-company-decision/
- Date we read it
- . This is not a fresh check.
- Date the provider printed
- Not displayed
- What we checked
- We read the provider's public page. We have not verified availability, eligibility or outcomes for any individual.
Other starting points
- 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
Center for Medicare Advocacy self-help materials
Downloadable self-help toolkits for Medicare denials involving home health care, outpatient therapy and skilled nursing facility care, from a nonprofit law organization. The page describes materials, not a helpline.
From Center for Medicare Advocacy