{
 "cite": {
  "title": "How to appeal a denied US health insurance claim, the two free appeals",
  "url": "https://denialfacts.com/how-to-appeal",
  "publisher": "Axion Labs — Denial Facts",
  "checked": "2026-09-05",
  "dataset": {
   "version": "2026-09-05",
   "fixity": "sha256-70fcef553523e50058a299023fafac57763341dfadc1bbd86b956b6fe1079dd3"
  },
  "source": {
   "name": "CMS Transparency in Coverage Public Use File (PY2026 release, PY2024 claims), data.healthcare.gov",
   "url": "https://data.healthcare.gov/"
  },
  "rule": "45 CFR 147.136",
  "license": "free to quote with the URL",
  "receipt": null
 },
 "query": {
  "insurer": null,
  "state": null,
  "reason": null
 },
 "resolved": {
  "insurer": null,
  "state": null,
  "state_inferred_from_insurer": false,
  "reason": null
 },
 "unresolved": null,
 "insurer": null,
 "state": null,
 "reason": null,
 "national": {
  "denial_rate_pct": 18.7,
  "claims_received": 451249792,
  "claims_denied": 84502749,
  "internal_appeals_filed": 263021,
  "internal_overturn_pct": 32.6,
  "external_reviews_filed": 5881,
  "external_overturn_pct": 32.8,
  "one_external_review_per_n_denials": 14369,
  "issuers_in_file": 185,
  "states_in_file": 30
 },
 "federal_appeal_rights": {
  "summary": "Two appeals, both free, both created by federal law. Nationally 32.6% of internal appeals and 32.8% of external reviews go the patient's way, yet only 1 in 14,369 denials ever reaches external review.",
  "internal_appeal": {
   "decided_by": "Your insurer, by someone not involved in the first decision",
   "deadline_to_file": "Generally 180 days from the denial notice",
   "cost": "Free",
   "decision_time": "30 days before service, 60 days after service, about 72 hours expedited",
   "national_overturn_pct": 32.6
  },
  "external_review": {
   "decided_by": "An independent review organization that does not work for your insurer",
   "deadline_to_file": "Generally four months from the date of the final internal denial",
   "cost": "No charge under the HHS-administered federal process; where an issuer-contracted IRO or a state process is used a fee may apply, capped at $25",
   "decision_time": "No later than 45 days standard, no later than 72 hours expedited",
   "binding": "Yes, the insurer is required by law to accept the decision",
   "national_overturn_pct": 32.8,
   "qualifying_denials": "Denials involving medical judgment, denials on the basis that a treatment is experimental or investigational, and rescission of coverage. A purely administrative or eligibility denial may not qualify for external review, but is still fully appealable internally."
  },
  "erisa_document_rights": {
   "applies_to": "Employer-sponsored (ERISA) group health plans",
   "note": "These are the four rights the site is built on, the ones that force a reasoned answer instead of a rubber-stamp. Marketplace and individual plans get the parallel ACA rights.",
   "rights": [
    {
     "right": "Your complete claim file, free of charge",
     "detail": "On request and free of charge, you are entitled to reasonable access to and copies of all documents, records and other information relevant to your claim, including the clinical criteria applied and the reviewer's reasoning. Ask before you argue: you cannot rebut criteria you have not read.",
     "citation": "29 CFR 2560.503-1(h)(2)(iii)"
    },
    {
     "right": "The plan's own policy or guidance for your condition, in writing",
     "detail": "A plan's statement of policy or guidance concerning the denied treatment for your diagnosis is itself a relevant document, so it must be produced on request, that is the medical policy your appeal has to answer. The review must also take into account all information you submit, whether or not it was before the plan on the first decision.",
     "citation": "29 CFR 2560.503-1(m)(8)(iv), with (h)(2)(iv)"
    },
    {
     "right": "A reviewer who was not the original decision-maker",
     "detail": "The appeal must give no deference to the original decision and must be decided by someone who is neither the original decision-maker nor their subordinate. If the names you obtain from the claim file show otherwise, that is a procedural violation and belongs in your external review request.",
     "citation": "29 CFR 2560.503-1(h)(3)(ii)"
    },
    {
     "right": "Medical judgment reviewed by an appropriate clinician, a different one",
     "detail": "Where the appeal turns on medical judgment, the plan must consult a health care professional with appropriate training and experience, and that consultant must not be the professional consulted on the original denial, nor their subordinate.",
     "citation": "29 CFR 2560.503-1(h)(3)(v)"
    }
   ]
  },
  "free_help": [
   {
    "who": "Your state Consumer Assistance Program or Department of Insurance",
    "note": "Free, and can intervene with the insurer directly"
   },
   {
    "who": "HealthCare.gov",
    "note": "Federal guidance on both appeal stages"
   },
   {
    "who": "US Department of Labor",
    "note": "For employer plans, 1-866-444-3272"
   }
  ]
 },
 "attribution": {
  "source": "Denial Facts (https://denialfacts.com) — computed from the CMS Transparency in Coverage Public Use File",
  "upstream": "CMS Transparency in Coverage Public Use File (PY2026 release, PY2024 claims), data.healthcare.gov — US Government public domain",
  "upstream_license": "US Government public domain",
  "facts_checked": "August 3, 2026",
  "license": "Free to use, including commercially, with attribution and a link to https://denialfacts.com",
  "operator": {
   "name": "Axion Labs",
   "email": "hello@getaxionlabs.com"
  },
  "disclaimer": "Federal statistics and a general description of appeal rights created by federal law. Not legal, medical, or insurance advice, and no outcome is guaranteed. Your denial letter and plan documents govern your specific case."
 },
 "citation": {
  "cite_as": "Denial Facts (https://denialfacts.com), from CMS Transparency in Coverage Public Use File (PY2026 release, PY2024 claims), data.healthcare.gov — US Government public domain. Appeal-rights facts checked August 3, 2026.",
  "link": "https://denialfacts.com",
  "llms_txt": "https://denialfacts.com/llms.txt",
  "pages_backing_this_answer": [
   "https://denialfacts.com/how-to-appeal"
  ]
 },
 "notice": "Free with attribution — the citation object in this response says how. Building on this endpoint? Write to hello@getaxionlabs.com (a person answers) and tell us the endpoint or field you need; we build it.",
 "receipt": {
  "v": "answer-receipt/v0",
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  "alg": "Ed25519",
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  "signed_at": "2026-09-22T14:43:26.919Z",
  "dataset_version": "2026-09-05",
  "policy": "axion-receipt/v1: sha256 over the body minus this receipt, dataset 2026-09-05, fields as served",
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  "public_key": "https://denialfacts.com/.well-known/answer-key",
  "verify": "https://denialfacts.com/api/verify-receipt",
  "what": "Detached Ed25519 signature over this response minus this receipt field. Proves what this door said, when, and from which dataset version, not that the answer is true; the trust block carries how the data was checked."
 }
}