Insurance companies deny 1 in 8 in-network claims. Most people just pay. But appealing wins about 40% of the time — here's how.
Step 1: Read the Denial Letter Carefully
The letter must include:
- Specific reason for denial
- Your right to appeal
- Deadline to file appeal (usually 180 days)
- Internal appeal process
- External review rights
Step 2: Identify the Denial Type
- Not medically necessary — most common, easiest to appeal with doctor's letter
- Out-of-network — appeal if it was emergency or no in-network alternative
- Pre-authorization missing — sometimes provider's fault; can be retroactively approved
- Experimental/investigational — needs strong evidence appeal
- Coding error — provider can fix and resubmit (50% of denials are admin errors)
Step 3: First-Level Appeal (Internal)
- Call your insurer to confirm appeal process
- Request a "peer-to-peer review" — your doctor talks to their medical reviewer
- Submit written appeal within deadline
- Include doctor's letter explaining medical necessity
- Cite plan documents (SBC) showing coverage
- Decision in 30 days (15 if expedited)
Step 4: External Review (If Internal Fails)
Under federal law, you have the right to an independent external review. An outside organization reviews your case — and they overturn denials about 50% of the time.
- File within 4 months of internal denial
- Typically free
- Decision in 60 days (72 hours if urgent)
- Decision is binding on the insurer
What Actually Works
- Strong physician letter — explains why treatment is medically necessary, cites guidelines
- Cite specific plan language — quote the SBC showing coverage
- Reference clinical guidelines — UpToDate, AHRQ, professional society recommendations
- Submit recent studies — for newer treatments
- State insurance commissioner complaint — escalate if insurer drags feet
Get Help
- Patient advocate (free): Contact your state's Consumer Assistance Program
- Doctor's office: Many have billing specialists who appeal for you
- Insurance broker: If you bought through one, they often help appeal
- Lawyer: For high-dollar denials ($10K+) — many work contingency
Got a denial? Our licensed agents help with appeals — even if you didn't enroll through us. Get free appeal help →