Your claim was denied as "not covered" or excluded. Is that the end?

My claim says the service is not covered. Can I still appeal?

Yes. If your insurer denies a claim, you can ask it to reconsider. Insurers have to tell you why they denied the claim and how you can dispute the decision, so look for that explanation in your denial letter.

You can ask the insurer for a full and fair review of its decision. If the denial stands, you may be able to ask an independent third party to review it.

How long do I have to appeal a denial?

HealthCare.gov says you must file an internal appeal within 180 days (6 months) of receiving notice that your claim was denied. Put the date you received it at the top of your notes today.

If you then ask for an external review, HealthCare.gov says to file a written request within 4 months after you receive the insurer's final notice. Rules can differ by plan type (employer plan, Marketplace plan, Medicare, Medicaid), so the dates in your own denial letter are the ones to follow.

How do I find out if my plan really excludes this?

Ask your insurance company or group health plan for a copy of your Summary of Benefits and Coverage. You can ask for it any time.

Read it next to the denial letter. Check whether the exact service is named, or whether the letter used a broad reason. If the two do not match, say so in your appeal.

What do I send in to appeal?

Follow these steps to start.

Keep your original records and send copies of them. Keep a copy of your appeal letter too.

• Step 1: Write down your dates. Note the date you received the denial, plus your claim number and member ID.
• Step 2: Get your plan papers. Ask your insurer for your Summary of Benefits and Coverage and read the exclusion that was cited.
• Step 3: Gather support. Collect your Explanation of Benefits, a letter from your doctor, and notes from every phone call with the day, time, name and title of the person you spoke with.
• Step 4: File the appeal. Use the insurer's form, or write to the insurer with your name, claim number and member ID. Your state's Consumer Assistance Program can file an appeal for you.

Who decides if my appeal is rejected?

The internal appeal is decided by your insurer. After that, you may be able to take it to an independent external reviewer. If your case goes to external review, your insurer is required by law to accept the reviewer's decision.

HealthCare.gov lists denials that involve medical judgment and treatments the plan calls experimental or investigational as ones that qualify. It does not say whether a plain exclusion qualifies, so ask your state's Consumer Assistance Program or Department of Insurance whether yours does.

What if I have Medicare and the service was not covered?

Medicare has its own appeal process. You can appeal if you disagree with a coverage or payment decision by Original Medicare, your Medicare health plan or your drug plan. There are generally 5 levels of appeal.

Your plan must tell you in writing how to appeal. For free counseling, contact your State Health Insurance Assistance Program (SHIP).

What does CheckMyDenial do?

Text a photo of your denial letter to (213) 606-6303. We read it and reply with where it breaks. It is free, with no account and no form. We are not lawyers, and this is not legal or medical advice.

Your checklist

• Write down the date you got the denial letter
• Circle the exact reason or exclusion it cites
• Ask your plan for your Summary of Benefits and Coverage
• Ask your doctor for a short letter explaining the need
• Keep call notes: day, time, name, title
• File the appeal by the deadline in your letter (HealthCare.gov says 180 days for internal appeals)
• Keep your originals and send copies of your records

A letter you can copy

[Date] [Insurance company name] Appeals Department [Address] Re: Appeal of claim denial Member name: [Your name] Member ID: [ID number] Claim number: [Claim number] Date of service: [Date] Date I received the denial: [Date] To the Appeals Department, I am appealing the denial of the claim above, which was denied as [reason given in the letter]. I am asking for a full and fair review of this decision. Please send me a copy of the plan language you relied on, and my claim file. I am enclosing copies of my Explanation of Benefits, a letter from [doctor name], and my call notes. Please confirm in writing that you received this appeal, and tell me how to ask for an external review if the denial stands. Sincerely, [Your name] [Phone number]

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

• Your claim was denied for being filed too late. Here is what that means and what you can do.
• Denied as a duplicate claim: what it means and how to fix it
• 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.