How to appeal a denied health insurance claim
Two appeals, both free, both created by federal law. Most people use neither. The ones who reach the second win nearly half the time.
Stage 1 — internal appeal
| Question | Answer |
|---|---|
| Who decides | Your insurer (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); 72 hours expedited |
| Nationally overturned | 43% |
Stage 2 — external review (the one nobody uses)
| Question | Answer |
|---|---|
| Who decides | An independent organization — not your insurer |
| Deadline to file | Four months from the date of the final internal denial notice |
| Cost | No charge under the HHS-administered federal process. If your issuer uses a contracted independent review organization or a state process, a fee may apply — capped at $25 per review |
| 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 |
| Nationally overturned | 44% |
Which denials qualify for external review. Not every denial does. External review covers denials that involve medical judgement, 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 it is still fully appealable internally, and administrative denials are often the easiest to reverse there.
Notice, current as of August 2026: HealthCare.gov states that the HHS-Administered Federal External Review Process was temporarily unavailable as of 1 July 2026, affecting people in Alabama, Florida, Georgia, Texas, Wisconsin and US territories other than Puerto Rico whose plan uses that process. HHS has said it is working on a solution and will give information about extending deadlines. If this affects you: follow the instructions in your own denial notice, keep evidence of when you tried to file, and check HealthCare.gov for the current position.
The gap this site exists for: 57,590,788 denials, 2,336 external reviews. One in 24,654. Nearly half of those who go win, and the insurer has to comply.
What makes an appeal work
- Answer the stated reason. Find the exact denial category on your letter and argue that point — reason by reason here.
- Demand the file first — this is the strongest move most people never make. Under the federal claims regulation (29 CFR 2560.503-1) you are entitled, on request and free of charge, to reasonable access to and copies of all documents, records and other information relevant to your claim — including the clinical criteria they applied and the reviewer's reasoning. Your denial letter is legally required to tell you this right exists. Ask before you argue: you cannot rebut criteria you have not read.
- Letter of medical necessity from your treating clinician, referencing your records and current guidance.
- Keep to the deadlines — work yours out here.
- Ask for expedited handling if delay would seriously jeopardise your health.
Everything you need for your appeal: your two deadlines, the argument that fits your denial reason, an evidence checklist, and the external review request. Opens on screen the moment you pay.
This page presents federal statistics and a general description of appeal rights created by federal law. It is not legal, medical, or insurance advice, and no outcome is guaranteed. Your denial letter and plan documents govern your specific case. Free help is available from your state's Consumer Assistance Program and from the federal Marketplace at HealthCare.gov.