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In short Start with the reason Step one: the internal appeal Step two: the external review If the situation is urgent Medicare and Medicaid are different Protect the bill while you fight Common questions SourcesA denial is not the final word. You have the right to an internal appeal, where your insurer reviews its own decision, and then to an external review, where an independent third party decides and your insurer must accept the outcome. Both are free. Deadlines matter, so start with the denial letter.
Start with the reason
Your insurer has to tell you why it denied the claim or ended your coverage, and how to dispute the decision. That explanation is on the denial letter and often on your explanation of benefits. Our guide on reading an EOB can help decode it. Some denials come from fixable problems: a coding error, a missing prior authorization, or a claim sent to the wrong place. Our prior authorization guide covers that piece.
Step one: the internal appeal
HealthCare.gov says you must file your internal appeal within 180 days (6 months) of receiving the denial notice. You complete your insurer’s required forms, or write to the insurer with your name, claim number and insurance ID number. The insurer then has 30 days to decide if the appeal is about care you have not received yet, and 60 days if it is about care you already received.
Step two: the external review
If the insurer still says no, you can request an external review, where an independent third party looks at the decision. You must file that request within 4 months of the final denial. Standard external reviews are decided no later than 45 days after the request. The insurer is required by law to accept the reviewer’s decision, and the review costs you nothing.
If the situation is urgent
Urgent cases move faster. Insurers must decide urgent internal appeals within 72 hours, and you can ask for an external review at the same time as your internal appeal instead of waiting. Expedited external reviews are decided within 72 hours, depending on medical urgency.
Medicare and Medicaid are different
The process above applies to Marketplace plans and most private insurance. Medicare has its own multi-level appeals process, described on Medicare.gov, and Medicaid appeals run through your state. The deadlines and forms differ, so use the process your coverage names in its denial letter.
Protect the bill while you fight
Tell the provider’s billing office that you are appealing and ask them to hold the account rather than send it to collections. If the bill itself looks wrong, our guides on disputing a medical bill, the No Surprises Act and Good Faith Estimates cover the related rights.
- HealthCare.gov - How to appeal an insurance company decision
- HealthCare.gov - Internal appeals
- HealthCare.gov - External review
Common questions
Does appealing cost anything?
No. Internal appeals and external reviews are free. You can also ask your state’s insurance department for help at no charge.
How long do I have to appeal?
HealthCare.gov says 180 days (6 months) from the denial notice for the internal appeal, and 4 months from the final denial for an external review. Medicare and Medicaid have their own deadlines.
What are my chances?
Insurers do not publish a universal overturn rate, and outcomes depend on the reason for the denial. Denials based on paperwork errors or missing information are often fixable, which is why the denial letter matters.
Can Pymander help with a denial?
Pymander can explain insurance terms and help you organize what to ask your insurer or the billing office. It is not an insurer, a lawyer or a billing service. Pymander is available in all 50 states.