Can I appeal a denied claim without a lawyer?

Can I appeal a denied insurance claim myself?

Yes. The first step, called an internal appeal, is a request to your own insurer to take another look. You can do it yourself by completing the insurer's form or writing a letter with your name, claim number and health insurance ID number.

Attach a copy of your denial letter or Explanation of Benefits, plus anything that supports your case, such as a note from your doctor. Keep the originals and send copies. You are not alone in this, and a denial is not the final word.

How long do I have to appeal a denied claim?

For many health plans, HealthCare.gov says you must file your internal appeal within 180 days (6 months) of receiving the denial notice. Your plan type matters: Medicare, Medicaid, dental-only plans and some employer plans can follow different rules and deadlines. Medicare says your plan must tell you in writing how to appeal, and your denial letter should say how and by when.

Put the date you received the letter on your calendar today, and file well before the last day.

How long does the insurer have to answer my appeal?

Under the rules HealthCare.gov describes, an internal appeal must be completed within 30 days for care you have not received yet and within 60 days for care you already received. For urgent cases, the decision must come as quickly as your health requires and no later than 4 business days after your request.

Other plan types, such as Medicare and Medicaid, have their own timelines, so check the letter you got.

How do I appeal a denial step by step?

Here is a simple path you can follow at your kitchen table.

• Step 1: Read the denial letter. Find the reason given, the claim number, your ID number and the appeal deadline.
• Step 2: Gather your papers. Collect the denial letter, your Explanation of Benefits, any bills, and a letter from your doctor if you can get one. Write down dates and names from phone calls.
• Step 3: Send your appeal in writing. Use your insurer's form or a short letter. Explain why the decision is wrong and ask for it to be reversed. Keep copies and proof of how and when you sent it.
• Step 4: Ask for outside review if it is denied again. If the insurer says no, ask whether your plan offers external review. Under the process HealthCare.gov describes, you request it in writing within 4 months of the insurer's final decision. Medicare and Medicaid use their own next steps, which your letter will explain.

Is there free help with an insurance appeal?

Yes. Many states run Consumer Assistance Programs that help people with health insurance problems by phone, email, mail or in person, and HealthCare.gov says your state program can file an appeal for you. If your state does not have one, your state department of insurance is another place to ask.

If you have Medicare, your local State Health Insurance Assistance Program (SHIP) offers free, personalized counseling. Find yours at shiphelp.org. HealthCare.gov also lists a help line at 1-800-318-2596 and a local help finder at localhelp.healthcare.gov.

What if my insurance company denies my appeal?

You may be able to ask for an external review, where someone outside your insurer decides. HealthCare.gov says this covers denials that involve medical judgment, care the insurer calls experimental or investigational, and cancelled coverage. Under that process, the request is made in writing within 4 months of the insurer's final decision, and standard reviews are decided within 45 days, with expedited reviews within 72 hours or sooner for urgent situations.

HealthCare.gov says there is no charge under the HHS-administered process, and if a state process or an independent review organization handles it, the charge cannot be more than $25 per review. The insurer is required by law to accept the reviewer's decision. Medicare and Medicaid have their own appeal levels, so follow the steps in your decision letter.

When is it worth hiring a lawyer for a denied claim?

Plenty of people handle appeals on their own. It may be worth talking to a lawyer if a very large amount is at stake, if you have lost both the appeal and the outside review, if your insurer is not following the deadlines it gave you, or if you simply feel stuck.

We are not lawyers and this is not legal advice. Start with the free helpers above, and bring a lawyer in if the situation outgrows them.

Your checklist

• Find the date you got the denial letter and write the appeal deadline on your calendar
• Circle the reason the denial letter gives
• Check what kind of plan you have (job, Marketplace, Medicare, Medicaid or dental-only), since the rules differ
• Gather the letter, your Explanation of Benefits and any bills
• Ask your doctor for a short supporting letter
• Write or fill out your appeal, and keep a copy
• Send it a way you can prove, then note the date
• Call your state consumer assistance program or insurance department if you want a hand

A letter you can copy

[Today's date] [Insurance company name] Attn: Appeals Department [Insurer address or fax] Re: Appeal of denied claim Patient name: [Full name] Member ID: [Health insurance ID number] Claim number: [Claim number] Date of service: [Date] Date I received the denial: [Date] To the Appeals Department, I am writing to appeal the denial of the claim listed above. The denial letter says the reason was: [reason given in the letter]. I believe this decision should be reversed because [one or two plain sentences, for example: my doctor says this care was needed because...]. I have attached: [denial letter / Explanation of Benefits / doctor's letter / bills / other]. Please review this appeal and send me your written decision. If you uphold the denial, please send me the full reason and information about how to request an external review. Thank you, [Your name] [Phone] [Address]

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• My insurance denied the claim but the provider says I owe the bill
• Internal appeal vs external review: what is the difference?
• How to read an insurance denial letter
• How to write an insurance appeal letter
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.