How to Appeal a Health Insurance Claim Denial: Internal Appeal and External Review
Learning goal: Know the steps and deadlines to appeal a denied health insurance claim, what to send, and when an independent external review can overrule your insurer.
Short answer
Start with an internal appeal: ask your insurer to reconsider, generally within 180 days of the denial notice, and include supporting documents like a letter from your doctor. If it still says no, you can request an external review by an independent reviewer within 4 months. If the reviewer decides in your favor, your insurer must accept it.
Read to the end to complete this lesson.
On this page
The Fuller Picture
The denial letter must explain why. Common grounds include prior authorization, medical necessity and out-of-network care. Denials involving medical judgment or experimental treatment can go to external review. For urgent situations, you can ask for both at once. Your state's Consumer Assistance Program can help, or file for you.
Key Takeaways
- HealthCare.gov: "You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied."
- Include the claim number, your ID number and supporting information, such as a letter from your doctor.
- File a written external review request within 4 months of the final denial.
- HealthCare.gov: "Your insurer is required by law to accept the external reviewer's decision."
- In urgent cases, ask for an external review at the same time as the internal appeal.
Real-World Example
Rosa
Rosa's insurer denies an MRI as not medically necessary. Within a few weeks she files an internal appeal with a letter from her doctor explaining the symptoms and earlier treatments. The insurer upholds the denial. Rosa requests an external review, and the independent reviewer decides the MRI was medically necessary, so the insurer must pay under the plan's terms.
Common Mistakes
- Not appealing at all; many people don't.
- Missing the 180-day deadline.
- Sending an appeal without the doctor's supporting letter.
- Not keeping copies and notes of calls.
Interactive Exercise
Build Your Appeal
Gather these before filing.
Tick each step as you do it. Your checklist is saved in this browser.
Knowledge Check
Question: Your internal appeal was denied. What can you do next?
Recommended Insurpedia Tools
- Insurance Preparedness Checklist: Twelve insurance questions worth having an answer to, with a place to learn more about each one you have not looked at yet. No score.
Related Insurance Terms
Related Scenarios
Questions to explore next
Questions readers often ask next about this topic:
- How do I write a health insurance appeal letter?
- What's the deadline for my appeal?
- Can my doctor file the appeal for me?
- Does my denial qualify for external review?
See every lesson in the Health Insurance course.
Explore the course →Sources
The factual claims on this page were checked against these sources. Rules and figures change, so check the source itself if you need to confirm the current version.
- healthcare.govInternal appeals · HealthCare.gov (U.S. Centers for Medicare & Medicaid Services)
- healthcare.govExternal review · HealthCare.gov (U.S. Centers for Medicare & Medicaid Services)
Educational information, not advice: This lesson is for general education only, not legal, financial, or insurance advice. Actual coverage, discounts, and requirements depend on your policy’s wording, your insurer, and the laws of your state. Confirm specifics with your own insurer or a licensed agent before making a decision. Insurpedia does not sell insurance and does not recommend specific insurers. Appeal steps and deadlines are from HealthCare.gov's internal appeals and external review pages. State rules and plan types (including some job-based plans) can differ. Educational information, not legal advice.