How to Appeal a Denied Health Insurance Claim
Denied a health insurance claim? Don’t panic - appealing is often worth it. Many people skip the appeals process, but statistics show that over 50% of appeals result in reversed decisions. Here's what you need to know:
Common reasons for denial: Errors in paperwork, lack of prior authorization, disputes over medical necessity, or out-of-network care.
Steps to appeal: Review your Explanation of Benefits (EOB), gather supporting documents (like medical records), and submit a clear, organized appeal letter.
Timelines: You typically have 180 days to file an appeal, with insurers required to respond within 30–60 days (or 72 hours for urgent cases).
External reviews: If the internal appeal fails, an independent review can still overturn the denial.
Act quickly, stay organized, and don’t hesitate to seek support from your healthcare provider or insurer. Appeals are underused but highly effective in securing the care you deserve.
Why Health Insurance Claims Get Denied
Most Common Denial Reasons
Paperwork errors - Incorrect info, missing signatures, or typos can trigger rejections.
No prior authorization - Some treatments require advance approval.
Medical necessity disputes - Claims may be denied if the insurer deems the treatment unnecessary.
Coverage exclusions - Services like cosmetic or experimental procedures may not be covered.
Out-of-network providers - Using providers outside your network without approval can lead to denials.
Coordination of benefits issues - Having multiple plans can cause confusion over who pays first.
Duplicate claims - Submitting the same claim more than once can result in rejection.
Late filing - Missed deadlines (often 90 days to 1 year) can void a claim.
How to Read Your Explanation of Benefits (EOB)
An EOB is not a bill - it explains how your insurance processed a claim, detailing charges, what was covered, and what you may owe. It includes key info like provider, service date, and claim number.
Pay special attention to remark codes (like CAGCs or CARCs), which explain payment adjustments. Denied claims fail coverage criteria, while rejected claims often have errors or missing info.
Look for specific denial reasons - such as services not covered or coverage lapses - and check if additional documentation is needed. Also, note your appeal deadline and follow the provided instructions. Review your EOB alongside bills and receipts to catch any discrepancies. With claim denials costing providers billions annually - often due to avoidable errors - a careful review can help prevent unnecessary costs.
Getting Ready for Your Appeal
When preparing for an appeal, gathering complete and well-organized evidence is key. The success of your appeal hinges on addressing the reasons for the denial directly. A solid preparation strategy can help avoid further rejections.
Documents You Need to Collect
Start with your denial letter and Explanation of Benefits (EOB) - these explain why the claim was denied and how it was processed. Gather original bills, receipts, and your policy documents (like the Evidence of Coverage) to identify plan terms that support your case. Keep records of all communications - note dates, times, and details from calls or emails with your insurer or provider, and save all messages or letters. Also collect medical records, test results, and treatment notes to show why the care was necessary.
With everything organized, consider professional help to strengthen your appeal.
Getting Support Letters from Your Healthcare Providers
Your healthcare providers can play a crucial role in the appeal process. Ask your doctor to write a letter of medical necessity. This letter should outline prior treatments, explain why the recommended treatment is necessary, and address the specific reasons for the denial. Collaborate closely with your medical team to ensure the letter clearly illustrates the importance of the treatment or service.
These letters are powerful tools that directly counter the denial reasons, adding weight to your claim.
How to Organize Your Documents
Once you've gathered all your materials, organizing them effectively is essential. The Patient Advocate Foundation emphasizes the importance of structured documentation:
"It's important to keep your medical information organized so that you can build a compelling counterargument addressing the original denial and provide supporting documentation."
Make copies of every document and retain proof of submission. If you're sending your appeal by fax, keep the transmission confirmation. For mailed appeals, use certified mail with a return receipt request. Always save copies of your appeal letter, supporting documents, and delivery confirmations.
A well-organized appeal package not only improves clarity but also adds credibility to your case.
How to File Your Appeal: Step-by-Step Guide
Filing an appeal can feel overwhelming, but breaking it into clear steps makes the process more manageable. Once you've gathered all your documentation and support letters, it's time to formally file your appeal. Keep in mind that the steps and deadlines can vary depending on the type of appeal you're pursuing. Knowing these details in advance can save you time and increase your chances of success.
Call Your Insurance Company First
Before starting your appeal, call your insurer to understand why the claim was denied and clarify your appeal options. Ask about required forms, steps, and deadlines specific to your plan type. Take notes - include the representative’s name, and the date and time of the call. Sometimes, denials are due to simple errors like incorrect codes or missing info. If so, your provider may just need to resubmit the claim. Once you have the details, you’ll be ready to move forward with your written appeal.
How to Write an Appeal Letter
Your appeal letter should be clear, professional, and fact-based. Begin with key details: your name, policy and claim numbers, denial date, your doctor’s info, and what was denied. Explain why the treatment is medically necessary and covered under your plan. Reference specific policy language and briefly describe your condition. Include supporting documents - medical records, a letter of medical necessity, research, or second opinions. If pre-authorizations were submitted, mention them. Keep your tone respectful and focused. Once your letter is ready, follow your plan’s next steps for submitting the appeal.
Internal vs. External Appeals: What’s the Difference?
An internal appeal is your first attempt to have the insurance company reconsider their decision. Joanna Morales, CEO of Triage Cancer, explains:
"An internal appeal is when you go back to the insurance company and you ask them to reconsider."
You typically have 180 days from the date of the denial to file an internal appeal. Insurers are required to respond within specific timeframes: 30 days for treatments not yet received, 60 days for treatments already received, and 72 hours for urgent care.
If the internal appeal doesn’t work, you can move on to an external appeal. This step involves an independent third party reviewing your case. Morales highlights the importance of this option:
"...every state now also requires those insurance companies to provide access to an external appeal, where you get to go outside of the insurance company to an independent entity, and they're going to take a look to see whether or not the care that's been prescribed to you is medically necessary. And if they decide that it is, that decision is binding on the insurance company..."
Key Differences Between Internal and External Appeals:
Reviewer: Internal appeals are handled by the insurance company, while external appeals are reviewed by an independent third party.
Decision: Internal appeal decisions are non-binding, but external appeal decisions are binding on the insurance company.
Timeline: Internal appeals take 30–60 days (or 72 hours for urgent cases), while external appeals take up to 45 days (or 72 hours for urgent cases).
Filing Order: Internal appeals must be completed first, except in urgent situations where you may file an external appeal immediately.
External appeals are often worth pursuing. On average, about 50% of external appeals result in decisions favorable to the patient. In urgent cases, you might even be able to skip the internal appeal process and go straight to an external review.
Statistics show that appeals are underutilized despite their success rates. Monica Bryant of Triage Cancer emphasizes:
"It is absolutely in somebody's best interest to try and appeal, because we know somewhere between 40% and 60% of all appeals are decided in favor of the patient."
In 2019 alone, 40.4 million health insurance claims were denied, but only 0.02% of those claims were appealed.
Track Everything You Submit
Keep copies of your appeal letter, documents, and proof of submission. For faxes, save the confirmation page. For mail, use certified mail with return receipt for proof of delivery. Organize all materials - including receipts and communication logs - in one place. You should receive confirmation within 7-10 days. If not, follow up with your insurer. Check in regularly and document every follow-up call - include the date, time, and representative’s name. Staying organized and persistent helps ensure your appeal gets the attention it deserves.
How to Make Your Appeal Stronger
Once you've filed your appeal, the next step is to make it as clear and convincing as possible. A strong appeal combines well-organized information with solid evidence to back up your request.
Make Your Information Easy to Read
Reviewers handle many appeals, so clarity counts. Organize your letter with bold headings and use bullet points to highlight key details. Keep paragraphs short and explanations simple - avoid medical jargon unless necessary. Start with a brief summary of what you're requesting, including your policy number, claim number, and denial date. Label and arrange supporting documents clearly, placing the most important items - like a doctor's letter - at the front. Clear formatting and strong evidence help your appeal stand out.
Include Medical Research and Guidelines
If your treatment was denied as "experimental" or "investigational", including medical research can help demonstrate that it aligns with accepted medical practices. Published studies and clinical guidelines are particularly useful for this purpose.
For example, in one case, peer-reviewed studies were used to successfully secure coverage for extended cancer treatment.
You can find relevant research using resources like PubMed or Google Scholar. PubMed, maintained by the National Institutes of Health, offers access to millions of medical research articles. Tools like the Outcomes4Me app can also help cancer patients find studies tailored to their specific diagnosis.
When presenting research, focus on studies that directly relate to your condition and treatment. Highlight key findings that support the necessity of your care. Include copies of relevant articles and cite treatment guidelines from respected medical organizations.
If you're filing a second appeal, include even more documentation than in your initial submission. At this stage, research studies and clinical guidelines can provide the objective evidence needed to show that your treatment follows established protocols.
For urgent cases, you may need to request an expedited review to avoid delays.
When to Ask for Expedited Review
If delaying care could seriously harm your health, you can request an expedited appeal. These reviews must be completed within 72 hours, compared to 30-60 days for standard appeals. Qualifying situations include rapidly worsening conditions, emergency procedures, or any case where treatment delays pose serious risks. Your doctor can help confirm urgency. In your appeal letter, clearly state you're requesting an expedited review and include a detailed note from your doctor explaining the medical need. Document your request and follow up to ensure it's being handled on the expedited timeline.
United National Healthcare Appeal Support
United National Healthcare offers a range of resources to assist you throughout the appeals process. From personalized guidance to practical tools, these resources are designed to make navigating your appeal more manageable and improve your chances of a favorable outcome.
Get Personal Help with Your Appeal
If you need assistance, United National Healthcare provides direct support through experienced representatives who can guide you step by step.
For immediate help, call the number on your member ID card. Members can reach support at 1-866-801-4409 (for employer-sponsored plans) or 1-800-523-5800 (for Medicare Supplement plans), with TTY access at 711.
Healthcare providers can also access 24/7 chat support through the Provider Portal or contact Provider Services directly at 877-842-3210 during business hours.
For more complex cases, United National Healthcare offers a peer-to-peer review process. This allows your healthcare provider to discuss pre-service denials directly with a medical director. To streamline the process, have the following information ready before reaching out:
Member name, date of birth, and member ID number
Details about the denied service
For prescription drug appeals, the medication name and your physician’s contact details
In urgent cases, customer service can arrange expedited reviews and provide interpreter services if needed.
Templates and Guides to Help You
United National Healthcare offers tools to streamline the appeal process. An interactive guide on the Member Portal walks you through each step, with tips on formatting and required details.
Submitting appeals online speeds things up - digital submissions are processed about five days faster than mail. The portal and API system also confirm receipt and track progress.
Use official forms, like the Medicare Plan Appeals & Grievances Form, and include key info: member ID, details of the denied service, and supporting documents. As Dr. Noor Ali advises, include "strong supportive documents - medical evidence, clinical notes, [and] professional statements."
For Medicare Part D appeals, start with a claim reconsideration. If needed, follow with a post-service appeal.
Key Steps for a Successful Appeal
Read the Denial Letter - Understand the reason and appeal instructions.
Call Your Insurer - Clarify details and confirm the appeal process.
Gather Documents - Include the denial letter, bills, medical records, and policy info.
Fix Simple Errors - Ask your provider to correct issues like coding mistakes or submit a letter of medical necessity.
Track Everything - Save proof of submission and log all communications.
Act Quickly - Submit your appeal before the deadline and stay organized throughout
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If your health insurance claim gets denied because of a paperwork error, don’t panic - it’s Stay calm - most paperwork errors are fixable. Call your insurer to clarify the issue and get instructions. Resubmit the corrected documents and keep records of all communication, including dates and names.
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Gather medical records and ask your doctor for a letter explaining why the treatment is essential. Reference your policy’s definition of medical necessity and include supporting guidelines. Write a clear, fact-based appeal to strengthen your case.
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An internal appeal asks your insurer to review the denial. You have up to 180 days to file. If that fails, an external appeal brings in an independent reviewer. Use it for complex or urgent cases where a fair, unbiased decision is needed.
