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An envelope from your insurer says your claim was denied. Before you panic or pay the bill yourself, know this: a denial is the start of a process, not the end of one. Under the Affordable Care Act you have the right to appeal, first inside the insurance company and then to an independent reviewer.
Figure out why it was denied
The explanation of benefits should state the reason in plain terms, though insurers are fond of codes. Common reasons include the service being deemed not medically necessary, missing prior authorization, a coding error by the provider’s office, the service being classified as experimental, or the claim being sent to the wrong plan when you have two. Coding errors are surprisingly common, so verify the basics before building a case.
Call your insurer and ask for the denial in writing with the specific policy language they relied on. You cannot argue against a reason you have not seen.
File the internal appeal
Start with your insurer’s internal appeal. You generally have at least 180 days from the denial to file, but check your plan documents for the exact deadline. Put it in writing even if you also call, and keep copies of everything.
Your appeal is stronger with evidence. Get a letter from your doctor explaining why the care was medically necessary, referencing your diagnosis and what happens without treatment. Attach relevant medical records, the original claim, and the denial letter. If the denial was about prior authorization, find out whether anyone requested it and what the response was.
The insurer must decide within a set timeframe: generally 30 days for pre-service claims and 60 days for claims for care you already received. If it is urgent, you can request an expedited review.
Take it to external review
If the internal appeal fails, you can request an external review by an independent third party. The reviewer looks at the medical facts fresh, and if they overturn the denial, the insurer must pay. This is free to you in most states, and external reviewers overturn denials at meaningful rates, so it is worth doing when the bill is large.
Your state insurance department or consumer assistance program can tell you how to file and what the deadlines are. Deadlines are strict at this stage, so calendar them the day you get the internal denial.
While you wait, protect your wallet
Do not ignore the provider’s bill during the appeal. Call the billing office, tell them an appeal is pending, and ask them to pause collections. Many will. Keep paying your premiums so the policy stays active. And review your plan’s cost-sharing rules so you know what you would owe even if the appeal succeeds; our explainers on out-of-pocket maximums and coinsurance help here. If the denied service relates to a condition your plan covers differently than you expected, read how pre-existing condition rules apply under current law.
