Appeal

An appeal is a formal request to have your health insurance company review and reconsider a decision to deny coverage, payment, or authorization for a service. You have the right to appeal any adverse benefit determination — including claim denials, prior authorization rejections, and coverage terminations.

There are two stages of appeal under ACA rules:

• Internal appeal: Your insurer reviews the denial within their own process. You must file within 180 days of receiving the denial notice. The insurer typically has 30–60 days to respond (shorter for urgent care).
• External review: If the internal appeal is denied, you can request an independent external review by a third-party organization. The external reviewer’s decision is binding on the insurer. This is the most powerful recourse available.

Common reasons to file an appeal:

• A claim was denied for a covered service
• Prior authorization was rejected for a medically necessary procedure
• Your insurer says a service is not medically necessary
• Your plan terminated coverage you believe was valid

When filing, include your explanation of benefits (EOB), any supporting documentation from your doctor, and a clear explanation of why you believe the denial was incorrect.