File an internal appeal

Guides

• 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.

• 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.

• 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.

Tools

• Tool

  Appeal letter builder

  Pick your denial reason and build an appeal letter with an enclosure list and a next-steps sheet.

• Tool

  Appeal packet builder

  Build a cover sheet and numbered enclosure list, with the steps to prove your appeal arrived.

• Tool

  Appeal tracker

  Track each level of your appeal, see the next deadline, and save the dates to your calendar.

• Tool

  Deadline calculator

  Turn the date on your notice into the dates you and the plan each have to meet, with the rule behind each one.

• Tool

  Decision clock

  Check whether your plan has taken longer than the law allows to decide, and what you can do if it has.

Letters and scripts

• Letter or script

  Appeal my Medicaid plan's cut and keep my services going

  Ask your Medicaid health plan to appeal a cut or ending of a service you already get, and to keep the service going while it decides. Ask within 10 calendar days of the notice, or before the change takes effect if that is later.

• Letter or script

  Appeal: approved, then denied

  Asks your plan to pay a claim for care it approved in advance, and to explain what changed and which plan provision lets it deny payment after approval.

• Letter or script

  Appeal: coding error and reprocessing

  Asks your plan to reprocess a claim that was denied because of a billing or coding mistake, after your provider has corrected and resubmitted it.

• Letter or script

  Appeal: emergency care denied

  Asks your plan to cover an emergency visit using the prudent layperson standard, judged on your symptoms at the time rather than the final diagnosis.

• Letter or script

  Appeal: ending of ongoing treatment

  Asks your plan to keep covering treatment it already approved while you appeal a decision to reduce or end it, and to decide before the benefit stops.

• Letter or script

  Appeal: equipment or supplies

  Asks your plan to cover medical equipment or supplies it denied, using your plan's own wording, your prescriber's order and how the equipment is used in your daily life.

• Letter or script

  Appeal: experimental or investigational

  Asks your plan to reverse an experimental or investigational denial, to explain its clinical reasoning for your diagnosis, and to answer the evidence your doctor relies on.

• Letter or script

  Appeal: filed too late

  Asks your plan to accept a claim it called late, by showing when it was first sent, quoting the plan's own filing rule, and asking it to apply any exception it contains.

• Letter or script

  Appeal: formulary exception

  Asks your plan to cover a drug that is not on its drug list, or to lift a quantity limit, using your prescriber's reasons why the covered alternatives do not fit.

• Letter or script

  Appeal: level of care

  Asks your plan to approve the level or setting of care your clinician recommended, such as a hospital stay or residential program, instead of a lower one.

• Letter or script

  Appeal: mental health or substance use care with a parity argument

  Asks your plan to reverse a mental health or substance use denial and to produce its criteria and comparative analysis under the federal parity law.

• Letter or script

  Appeal: not a covered benefit

  Asks your plan to name the exact provision it relied on and to cover care that falls within a benefit your plan document describes.

• Letter or script

  Appeal: not medically necessary

  Asks your plan to reverse a medical necessity denial, using the plan's own standard and your records, and to have a clinician in the right field review it.

• Letter or script

  Appeal: out of network because no in-network option exists

  Asks your plan to cover out-of-network care at the in-network level because no in-network provider could give the care in time, or at all.

• Letter or script

  Appeal: out-of-network allowed amount too low

  Asks your plan to explain how it set the allowed amount for out-of-network care, to reprocess the claim if the method was wrong, and to pay the difference.

• Letter or script

  Appeal: prior authorization denied

  Asks your plan to reverse a refusal of approval before care, to say what standard it applied, and to decide with a clinician in the right field.

• Letter or script

  Appeal: step therapy exception

  Asks your plan to excuse you from trying other drugs first, using the drugs you have already tried and your prescriber's reasons, and to send its step therapy rules.

• Letter or script

  Ask your employer to review the denial

  A polite written request to your employer's benefits office to look into a denial, name the plan administrator and send the plan documents.

• Letter or script

  Ask your plan to reprocess a claim under the No Surprises Act

  Ask your plan to reprocess a claim with the No Surprises Act protections, so you pay only in-network cost sharing that counts toward your in-network limits, and to treat the letter as an appeal if the claim stays denied.

• Letter or script

  Cover sheet for an appeal packet

  A one-page cover sheet that lists everything in your appeal packet and how you sent it, so nothing is missed and you can prove what arrived.

• Letter or script

  Medicaid fair hearing request

  Ask your state for a fair hearing when Medicaid denied, reduced or stopped a service. If you have a Medicaid plan, you appeal to the plan first.

• Letter or script

  Medicare Advantage reconsideration request

  Ask your Medicare Advantage plan to review its denial again. The plan's appeal is called a reconsideration, and an outside reviewer sees the case if the plan says no.

• Letter or script

  Medicare redetermination request

  Ask the Medicare contractor to review again a decision on your Original Medicare claim. This is the first appeal, called a redetermination.

• Letter or script

  Phone script: appeal to your Medicaid plan and keep services going

  What to say when you phone your Medicaid health plan to appeal a cut or ending of services and keep them going during the appeal, what to ask for, what to do if told the provider must ask, and what to write down.

• Letter or script

  Phone script: chase an appeal that has gone silent

  What to say and ask when you have filed an appeal and heard nothing, including the federal decision deadlines for job-based and individual plans.

• Letter or script

  Request an expedited appeal

  Asks your plan to decide an appeal as an urgent claim, within 72 hours, because waiting could seriously harm your health, and to contact your doctor.

• Letter or script

  Second-level internal appeal

  Asks for a second review inside your plan after a first appeal was denied, answering the first decision's reasons and adding what is new.

• Letter or script

  Tell the plan it missed its deadline

  A letter that tells your plan it did not decide your claim or appeal in time, quotes what the federal rule says follows, and asks the plan to confirm in writing what it did and where you now stand.

Checklists

• Checklist

  Internal appeal packet

  What to gather, include and send when you ask your plan to reconsider a denial, and what to track after you send it.

Programs and services

Run by other organizations.

• 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

• Program or service

  Connecticut Office of the Healthcare Advocate

  A free Connecticut state office that helps residents understand their benefits and speaks up for them when a claim or a prior authorization request (advance approval for care) is denied. Open to people with any kind of coverage.

  From State of Connecticut, Office of the Healthcare Advocate

• Program or service

  Coverage Rights state-by-state appeal steps

  A nonprofit website that gives each state's steps for appeal, external review and complaint when an insurer denies or delays a treatment, with a focus on medicines. No helpline or letters.

  From Aimed Alliance

• Program or service

  Disability Rights Florida guide to Medicaid fair hearings

  A step-by-step explanation of how to challenge a denial or reduction of Medicaid services in Florida, from notice to petition to hearing. For people with disabilities. Florida only.

  From Disability Rights Florida

• Program or service

  Filing a Claim for Your Health Benefits (Department of Labor booklet)

  A plain federal booklet on the claim and appeal rules for workplace health plans: the documents to check, how to file, the decision timeline, and your rights after a denial.

  From U.S. Department of Labor, Employee Benefits Security Administration

• Program or service

  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.

  From HealthCare.gov (Centers for Medicare & Medicaid Services)

• Program or service

  Immune Deficiency Foundation insurance appeals

  Guidance on appealing a denied claim or filing a complaint, aimed at people with primary immunodeficiency, with advice on peer-to-peer review and letters of medical necessity. Condition-specific: especially immunoglobulin therapy.

  From Immune Deficiency Foundation

• Program or service

  Indian Health Service Purchased/Referred Care: appeal a denial

  How American Indian and Alaska Native patients ask the Indian Health Service to reconsider a denial of payment for care received away from an Indian Health Service or tribal facility.

  From Indian Health Service

• Program or service

  KFF Health News: seven tips for fighting a health insurance denial

  A news article with seven tips for fighting a prior authorization denial, including knowing your plan type, working with your provider, staying organized, and asking for help. Written by a reporter, not by an agency.

  From KFF Health News

• Program or service

  Maryland Attorney General: Health Education and Advocacy Unit

  A free Maryland mediation service that helps with denied coverage from private health plans, plan terminations, surprise bills, hospital financial assistance and billing disputes.

  From Office of the Attorney General of Maryland, Consumer Protection Division

• Program or service

  Medicaid fair hearings: federal explainer

  A federal fact sheet on the right to a Medicaid fair hearing when a state denies, reduces or ends your Medicaid benefits, with hearing rights, deadlines that vary by state, and how benefits can continue.

  From Centers for Medicare & Medicaid Services, Medicaid.gov

• Program or service

  Medicare Interactive: Medicare appeals

  Free plain-language guides to appealing a Medicare denial, split by Original Medicare, Medicare Advantage and Part D drug coverage, from the Medicare Rights Center. Covers Medicare only.

  From Medicare Rights Center

• Program or service

  Medicare.gov: filing an appeal

  The official Medicare page on appealing a coverage or payment decision, with separate instructions for Original Medicare, Medicare health plans and drug plans, plus fast appeals when services end too soon.

  From Medicare.gov (Centers for Medicare & Medicaid Services)

• Program or service

  Patient Advocate Foundation appeals guide and sample letters

  A free 10-page guide to appealing a health plan denial, with a fill-in-the-blank appeal letter, from a patient-advocacy charity. It is written for most private plans and does not give your own deadlines.

  From Patient Advocate Foundation

• Program or service

  Patient Advocate Foundation case management

  Free one-on-one help from a case manager who can work on insurance denials and prior authorizations for patients with a serious or chronic condition who meet the program's rules. Intake is by phone and new cases are limited each day.

  From Patient Advocate Foundation

• Program or service

  Triage Cancer state-by-state health insurance appeals toolkit

  Free downloadable toolkit with general appeals guidance plus a section and forms for each state. Made by a cancer-focused legal-education nonprofit, but the page describes it as for people using health insurance and challenging denials.

  From Triage Cancer

• Program or service

  TRICARE appeals

  The official TRICARE page on the four kinds of appeal (factual, medical necessity, pharmacy, and Medicare-TRICARE), with mailing addresses for each regional contractor and the Defense Health Agency.

  From TRICARE (Defense Health Agency)

• Program or service

  Vermont Office of the Health Care Advocate (VTLawHelp)

  A free helpline for Vermonters with health care and health insurance problems, run as a project of Vermont Legal Aid. Its website also has plain-language pages on appeals, grouped by the kind of coverage you have.

  From Office of the Health Care Advocate, a project of Vermont Legal Aid

• Program or service

  Veterans Affairs clinical appeals and decision reviews

  How a veteran asks Veterans Affairs (VA) to review a treatment decision (a clinical appeal) or a decision about a VA benefit, including health care benefits, with the review options and what to send.

  From U.S. Department of Veterans Affairs