Appealing a Health Plan Denial: Internal and External Review

If your health plan denies a claim or ends your coverage, you have two levels of appeal: an internal appeal to the insurer, then an external review by an independent third party. The deadlines are short, and the clock starts when you receive the denial notice, not when you notice it.

Most denied claims are never appealed. The ones that are often succeed, particularly when the denial involves medical judgment that your doctor disagrees with. Knowing which path applies and which deadline you are on is most of the work.

Your right to appeal

The right is not discretionary. The Marketplace states that if your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the company's decision and have it reviewed by a third party.

It also places a duty on the insurer. The same page states that insurers have to tell you why they have denied your claim or ended your coverage, and that they have to let you know how you can dispute their decisions.

So the denial notice is not just a rejection. It is supposed to be an instruction manual for challenging it, and it should contain the deadline and the contact information you need. If a denial letter does not tell you how to appeal, that omission is itself worth raising.

The notice deadlines the plan must meet

Before you appeal, it helps to know what the plan was required to do and when, because a missed notice deadline supports your case.

The Marketplace lists three notice timeframes for a denial: within 15 days if you are seeking prior authorization for a treatment, within 30 days for medical services already received, and within 72 hours for urgent care cases.

The 72-hour urgent care window is the one to remember if you are in an active medical situation. It exists because a slow denial can function as a denial on its own when treatment is time-sensitive.

Internal appeal: the first level

An internal appeal is a request that your insurer conduct a full and fair review of its own decision. The Marketplace describes it as your right to ask your insurance company to conduct a full and fair review of its decision, and notes that if the case is urgent, your insurance company must speed up this process.

The process has a specific shape. The Marketplace describes three steps: you or a provider file a claim, the plan denies it in writing with a reason, and you file the internal appeal.

How you file is flexible. The Marketplace states that to file an internal appeal you need to complete all forms required by your health insurer, or you can write to your insurer with your name, claim number, and health insurance ID number. You can also submit any additional information that you want the insurer to consider, such as a letter from the doctor.

That last point matters more than it reads. A denial that turns on medical necessity is often overturned by a letter from the treating physician explaining why the service was needed. The appeal is your opportunity to put that in the record.

The internal appeal deadline

There is one number to remember here. The Marketplace states that you must file your internal appeal within 180 days, or 6 months, of receiving notice that your claim was denied.

Six months sounds generous until you consider how long it takes to obtain records and a physician letter. Treat it as a real deadline and start immediately.

Help filing

You do not have to do this alone. The Marketplace notes that the Consumer Assistance Program in your state can file an appeal for you. That is a free service and it exists specifically for this situation.

External review: the second level

If the internal appeal fails, external review takes the decision out of the insurer's hands. The Marketplace explains that you have the right to take your appeal to an independent third party for review, and that external review means that the insurance company no longer gets the final say over whether to pay a claim.

The outcome is binding on the insurer. The Marketplace states that your insurer is required by law to accept the external reviewer's decision.

The external review process has two steps: you file a written request, and an external reviewer issues a final decision that either upholds the plan or decides in your favor.

The external review deadline

This deadline is shorter than the internal one. The Marketplace states that you must file a written request for an external review within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied.

Four months, not six. Missing it generally means the decision stands.

Which denials qualify

Not every denial can go to external review. The Marketplace lists three categories:

• Any denial that involves medical judgment where you or your provider may disagree with the plan.
• Any denial that involves a determination that a treatment is experimental or investigational.
• Cancellation of coverage based on the insurer's claim that you gave false or incomplete information when you applied.

Source: External Review.

The first category is the broad one. A denial that the plan calls a medical necessity decision is exactly the kind of denial that external review exists to review.

Who runs it

External review is administered either by your state or by the federal government, depending on where you live. The Marketplace states that insurance companies in all states must offer an external review process that meets the federal consumer protection standards, and explains that if your state has a process meeting or exceeding those standards, insurers in your state follow the state process, while if your state does not, the Department of Health and Human Services oversees the process.

Where the federal government oversees it, insurers may either participate in an HHS-administered process or contract with an independent review organization. The practical point is that external review exists everywhere, but the route differs.

The Marketplace says to check the information on your Explanation of Benefits or on the final denial of the internal appeal, because it will give the contact information for the organization handling your external review.

The record you need to build

Documentation decides these cases. The Marketplace lists what to keep, and it is worth treating as a checklist:

• The Explanation of Benefits forms or letters showing what payment or service was denied.
• A copy of the request for an internal appeal you sent to the insurer.
• Any documents with additional information you sent, such as a letter from your doctor.
• A copy of any authorization form if you chose to have your doctor or someone else file on your behalf.
• Notes and dates from phone conversations, including the day, time, name, and title of the person you spoke with and details of the conversation.

Source: Internal appeals.

The phone-call log is the item people skip and later regret. A conversation where a representative said something inconsistent with the written denial can be decisive, but only if you can date it and identify who said it.

Medicare's guidance on record keeping makes the same point in a different context: keep your original documents and submit copies. The same discipline applies here.

Practical sequence

Work through this in order, and note the two separate deadlines.

1. Read the denial notice and find the reason and the appeal instructions. Note the date you received it, because every deadline runs from there.
2. Decide whether the case is urgent. If it is, ask for an expedited internal appeal and note that urgent cases carry a 72-hour notice requirement.
3. Gather the clinical evidence. Ask your treating provider for a letter explaining the medical necessity, and include it with the appeal.
4. File the internal appeal within 180 days. Use the plan's forms or write with your name, claim number, and ID number.
5. Consider state consumer assistance. A Consumer Assistance Program may be able to file on your behalf at no cost.
6. If the internal appeal fails, file for external review within 4 months of the final denial, using the contact information on that denial.
7. Keep everything, and keep copies of what you send.

Two timing cautions. The 180-day and 4-month clocks are separate and both run from the relevant notice, so a slow internal appeal does not extend the external review window in a way you should rely on. And if you use an expedited process, confirm in writing when the decision is due.

One further point for anyone whose appeal involves an ongoing course of treatment rather than a single claim: the appeal protects the claim, not necessarily the treatment schedule. Ask the plan, in writing, what happens to your appointments while the appeal is pending.

If you are dealing with a denial and want help reading the plan documents before you file, ask NavaQuote about health coverage options. Bring the denial notice, your Explanation of Benefits, and any letter from your provider. Our metal tiers guide explains what cost sharing the plan is supposed to apply, and our off-exchange ACA plans guide covers what to check in plan documents before you enroll, which is when these disputes are best prevented.

Appeal deadlines, plan terms, and external review processes can change, and the specific dates that apply to you are the ones on your own denial notice. Confirm them there rather than from any summary.