The denial letter from your insurer will be your road map to filing an appeal. Ask for your denial notice in writing if you don’t already have it. The notice, often called a Notice of Adverse Benefit Determination or Explanation of Benefits (EOB), reveals why you were denied and outlines your rights to appeal.
“Unfortunately, this happens far more often than it should,” says Graham. “If your insurer stalls, you need to report it to your regulator,” which is typically the state or federal agency that oversees your health insurer or employer plan. This may be your state’s insurance agency if you purchased a plan through the Health Insurance Marketplace or the U.S. Department of Labor for self-insured employer-sponsored plans.
Write Your Appeal Letter
Next, write and submit your appeal. In the letter, explain why you believe the denial was wrong, what treatment you need, and why it’s medically necessary. Include any relevant background or history, especially if you’ve tried other treatments. Also ask your doctor to write a supporting letter, since their clinical judgment carries weight. “What matters most is that it’s honest, direct, and backed by medical facts,” says Graham.
Request Your Claim File
Many people aren’t aware that they should ask their insurer for their claim file, which includes all the documents, emails, call logs, and internal notes used to make the decision. “Legally you’re entitled to see it, and it’s one of the most powerful tools you have to spot mistakes and strengthen your case during the appeals process,” says Graham.
To access your claim file, send a written request and follow up by phone if necessary. If your insurer doesn’t respond within 30 days, file a complaint with the agency that regulates it.
Internal vs. External Review
There are two types of appeals: an internal review and an independent, or external, review. In an internal review, you have up to 180 days (or about six months) to file the appeal, says Teri Dreher Frykenberg, RN, a patient advocate and the founder of Nurse Advocate Entrepreneur based in Monson, Massachusetts. If you have already received the medical service, your insurer must respond within 60 days. If you haven’t received the service yet, it must respond within 30 days.
“Sometimes your well-being or even your life is contingent on getting a prompt appeal; if so, you can request an expedited process,” she says. Your plan must make a decision on an urgent appeal within four days.
If your internal appeal is denied, your plan must give you instructions on how to request an independent, external review. If you have an urgent situation, you can ask for an external review at the same time as your internal appeal. You have four months from the time your insurer denies your internal appeal to file for an external review.
Keep Copies and Follow Up
Before you submit your appeal, make copies of everything. Mark your calendar to follow up, and if you don’t hear back within the mandated time frame, escalate the issue to regulators if needed, says Graham. At the end of the internal appeals process, your insurer must provide you with a written decision and instructions on how to file an external review.
