In today’s healthcare landscape, insurance claim denials are increasingly common — and incredibly frustrating. Roughly 1 in 5 insurance claims were denied in 2024, leaving countless Americans with unexpected medical bills and uncertainty about their next steps.
Despite legal protections under the Affordable Care Act (ACA) guaranteeing the right to appeal, most people don’t follow through, and many appeals are rejected for avoidable administrative errors. But when the denial of coverage could cost you thousands of dollars, knowing how to appeal — and how to improve your chances — can make a big difference.
Here’s what you and your clients need to know if an insurer denies coverage for a procedure, test, or treatment.
Step 1: Understand Your Health Plan — and the Denial
Think of a health insurance appeal as a contract dispute. The language in your plan defines what’s covered and what isn’t, and denials often hinge on how that language is interpreted.
Start by reviewing your denial letter. It should include:
- The reason your claim was denied
- Instructions for how to appeal
- The timeline to file your appeal (usually up to 180 days)
- Information on assistance or support options
You can also call your insurance company directly to clarify the appeals process and any documents they require.
If your healthcare provider is asking you to pay the denied bill, notify them that you’re appealing and request they hold off on collections while your appeal is in progress. Ask your doctor’s office for help gathering documentation to support your case — including evidence that the treatment was medically necessary, not experimental, and falls within your plan’s coverage.
Step 2: Know the Two Types of Appeals
There are two levels of appeal available to you:
1. Internal Appeal
You can submit a request directly to your insurance provider for a review of their decision.
- Deadline: Within 180 days of receiving your denial
- Response time: Within 60 days if the service has already been provided
- Tip: If the denial puts your health or life at risk, request an expedited appeal
If the insurer upholds the denial — called a “final internal adverse benefit determination” — they are required to provide information on how to file an external appeal.
2. External (Independent) Review
An external review is conducted by an independent organization that has no ties to the insurance company.
- This third-party will assess whether the denial aligns with medical necessity and coverage under your plan.
- Success rates are much higher at this level, with 50–80% of denials overturned.
Step 3: Keep Meticulous Records
The strength of your appeal often depends on how well you can present supporting documentation. Keep a detailed file with:
- Medical records: Include doctor’s notes, diagnosis history, lab results, imaging, and treatment plans
- Explanations of Benefits (EOBs): These outline what services were billed, what the insurer covered, and what you owe
- Second opinions: If you sought an independent medical opinion, include it
- Correspondence: Save letters, emails, denial notices, and notes from calls with your insurer
- Pre-authorizations: Include any prior approvals or related documents
- Medical research: Professional articles or studies that support your treatment can strengthen your case, especially if it’s deemed “experimental” by the insurer
A patient advocate or a healthcare attorney can assist in organizing these materials and navigating the appeals process.
In Conclusion: Don’t Give Up
Appealing a health insurance denial can feel like an uphill battle, but it’s often worth the effort. With the right information and support, you can improve your chances of getting the coverage you deserve.
If you’re facing a denial, act quickly, gather your documentation, and don’t hesitate to seek expert help. Appeals succeed more often than many people think — especially when handled correctly.
At Market Advisory Group, we understand how these unexpected expenses can impact your financial plan. Whether you’re navigating health insurance issues or planning for future medical costs in retirement, our team is here to help you protect your wealth and your well-being.
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