To file an appeal, start with your denial letter — that’s your road map. Demand 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 appeal rights.
“If your insurer stalls, you need to report them to your regulator,” the agency that oversees your health insurer, says Graham. “Unfortunately, this happens far more often than it should.”
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. Ask your doctor to write a supporting letter; 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
Something most people don’t know to do that can make or break your case is to ask for your claim file, which includes all the documents, emails, call logs, and internal notes your insurer used to make their 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 them. 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 most employer-sponsored plans.
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.
“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.
Keep Copies and Follow Up
Once you submit your appeal, keep 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.
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