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Health insurance denial: first steps

A denial is a decision, not always the last word. This checklist covers the first steps for most health plans. It is general information, not advice about your case.

1. Read the notice and find three things

• The reason. Not covered, not medically necessary, experimental, out of network, missing information, and so on. Each leads to a different appeal.
• The deadline and where to send an appeal. For employer plans the federal minimum is at least 180 days after you receive the denial, and for Marketplace plans it is 180 days. Your plan may allow longer. Some plans or other kinds of insurance may give less, so the date on your notice controls.
• What rules the plan used. The notice must explain the reason and include the plan rule, guideline or criteria used, or tell you how to request them.

2. Put the deadline on your calendar

Use the deadline estimator to get an estimated date and a calendar reminder, then plan to file about four weeks early, especially if mailing.

3. Call, then ask who is appealing

Call the number on your card, write down the date, name and what you were told, and ask for the exact appeal steps. Ask your doctor's or provider's office whether they have already filed an appeal or can send records. For a denial that depends on medical judgment, the clinician's letter often matters most.

4. Ask for the claim file and criteria

Plans must give you, on request and free of charge, copies of documents and information relevant to your claim. Use the claim file request letter. Sending it does not pause your deadline.

5. Appeal in writing and keep proof

Use the internal appeal letter. Keep copies of everything. Send in a way that gives proof of delivery, such as certified mail with return receipt or a fax confirmation or portal receipt.

6. If it is urgent

If a doctor says waiting could seriously harm your health, ask for an expedited appeal. Urgent appeals must be decided within 72 hours under the federal rules for group health plans, and the HealthCare.gov process also has a fast external review option.

7. Know what comes next

If the plan upholds the denial, ask about independent external review (4 months to request under the federal standard) and about a state insurance department complaint. Free help may be available from your state's Consumer Assistance Program (CAP) or, for Medicare, your State Health Insurance Assistance Program (SHIP).

Related guides

• How to read a health insurance denial letter
• How to file a health insurance internal appeal
• ERISA vs state-regulated health plans: why it matters
• State insurance department directory