Understanding Your Appeal Rights
Under the Affordable Care Act (ACA), all health insurance plans must provide you with the right to appeal claim denials. This is not optional - it is federal law. The appeals process has two main levels: internal appeals (within the insurance company) and external review (by an independent third party).
Statistics show that appealing is worth your time. According to research, roughly 40-50% of internal appeals are successful, and external reviews overturn denials 50-60% of the time depending on the state and type of denial.
Most plans require you to file an internal appeal within 180 days of receiving your denial letter. Miss this deadline, and you may lose your appeal rights entirely. Check your denial letter for the specific deadline that applies to your situation.
Internal Appeals: Your First Step
An internal appeal is your first chance to challenge a denial. The insurance company must have someone other than the original decision-maker review your case. For medical necessity denials, a qualified clinical professional must conduct the review.
Internal Appeal Required First Step
For most denials, you must exhaust the internal appeal process before requesting external review. This means filing one or more internal appeals depending on your plan type (most ACA plans require only one level of internal appeal).
Internal Appeal Timeline Requirements
| Appeal Type | Decision Deadline | When It Applies |
|---|---|---|
| Urgent/Expedited | 72 hours | Delay would jeopardize life, health, or ability to regain function |
| Pre-Service (Non-Urgent) | 30 days | Prior authorization or preservice claim denial |
| Post-Service | 60 days | Claim for services already received |
| Concurrent Care | 24 hours (urgent) / 30 days | Ongoing treatment being reduced or terminated |
What to Include in Your Internal Appeal
- Appeal letter - Clearly state you are appealing, reference the claim number, and explain why the denial was wrong
- Letter of medical necessity from your treating physician
- Supporting medical records - test results, imaging, chart notes
- Clinical guidelines - medical society guidelines supporting your treatment
- Peer-reviewed research - published studies supporting the treatment
- Personal statement - explain how the denial affects your health and life
Ask your doctor to request a "peer-to-peer" review where they speak directly with the insurance company's medical director. This can sometimes resolve denials quickly without a formal appeal process.
California law provides additional protections. Under California Health & Safety Code Section 1368, HMOs must respond to grievances within 30 days. For urgent matters involving an imminent and serious threat to health, the response time is 72 hours. For life-threatening conditions, it is 24 hours.
External Review: Independent Judgment
If your internal appeal is denied, you have the right to an external review. This is a review by an Independent Review Organization (IRO) - a third party with no connection to your insurance company. The external reviewer's decision is binding on the insurer (though you can still sue if you disagree).
External Review After Internal Appeal
External review must be requested within 4 months of receiving your final internal appeal denial. There is typically no charge for external review. The IRO reviewer will be a medical professional in a relevant specialty who will independently evaluate your case.
External Review Timeline Requirements
| Review Type | Decision Deadline | When It Applies |
|---|---|---|
| Standard External Review | 45 days | Most external reviews |
| Expedited External Review | 72 hours | Urgent situations or concurrent care reductions |
What Qualifies for External Review
- Medical necessity denials
- Denial of coverage for being "experimental or investigational"
- Rescission of coverage (cancellation of your policy)
- Any adverse benefit determination after internal appeal
External review is generally available only for medical judgment denials (medical necessity, experimental treatment). Purely administrative denials (wrong billing code, out of network) may not qualify. However, if an administrative denial involves any clinical judgment, you may still be eligible. Always request external review if you are unsure.
California has its own Independent Medical Review (IMR) program through the Department of Managed Health Care (DMHC). You can request IMR directly - you do not have to exhaust internal appeals first if you have been in the internal process for 30 days without resolution.
To file for California IMR, visit dmhc.ca.gov or call 1-888-466-2219. The process is free. For urgent cases, IMR decisions are made within 3 business days. Standard cases take about 30-45 days.
Expedited Appeals: When Time Is Critical
If waiting for the standard appeal timeline would seriously jeopardize your life, health, or ability to regain maximum function, you can request an expedited (urgent) appeal. The insurer must respond within 72 hours for internal appeals and 72 hours for external review.
When to Request Expedited Review
- You need immediate treatment (surgery, cancer treatment, etc.)
- Your condition is deteriorating while waiting
- You are in the hospital and coverage is being terminated
- Delay could result in permanent harm
- Your doctor certifies that delay is dangerous
Having your doctor provide a written statement that your situation is urgent significantly strengthens your expedited appeal request. Ask them to specifically state that delay would jeopardize your life, health, or ability to regain function.
Writing a Winning Appeal Letter
Your appeal letter is critical. Here is a structure I recommend:
Opening: State Your Purpose
"I am writing to formally appeal the denial of [specific claim/service] as stated in your letter dated [date]. My claim number is [number]. I believe this denial was made in error."
Background: Your Medical Situation
Briefly explain your medical condition, diagnosis, and why the denied treatment is necessary. Reference your medical records and your doctor's recommendations.
Address the Denial Reason
Quote the specific reason given for denial and explain why it is incorrect. Reference medical guidelines, research, and your doctor's letter of medical necessity.
Personal Impact
Explain how the denial is affecting you - pain, inability to work, impact on daily life, emotional distress. This helps humanize your case.
Closing: Clear Request
Clearly state what you want: "I request that you reverse this denial and approve coverage for [specific treatment]. Please respond within the timeframe required by law."
Make copies of every document you submit, note the date and method of submission (use certified mail or fax with confirmation), and keep a log of all phone calls with dates, times, and names of representatives.
What If Your Appeal Is Denied?
If both your internal appeal and external review are denied, you still have options:
- File a complaint with your state insurance commissioner or Department of Managed Health Care
- Consult an attorney about potential litigation (especially if you suspect bad faith)
- Contact your employer's HR if you have employer-sponsored insurance
- Ask your provider about payment plans or financial assistance if you must pay out of pocket
- Explore patient assistance programs for expensive medications
Related Guides
Need Help With Your Health Insurance Appeal?
I help patients navigate the appeals process, from crafting effective appeal letters to pursuing legal action when insurers act in bad faith. If your appeal has been denied or you are facing a complex situation, I can help.