Appeal a Private Health Insurance Denial¶
A private health-plan denial may be appealable. Start with the written denial or Explanation of Benefits (EOB), not a phone summary. The notice should explain the decision, the plan standard it used, and how to start an appeal.1
Use the appeal system named in the notice
This guide covers a private health plan or issuer's coverage decision. A Health Insurance Marketplace eligibility decision uses a different appeal process. If the notice names another program or appeal system, follow that notice rather than assuming these steps apply.
First: find the deadline, route, and exact reason¶
Put the denial notice in front of you and write down:
- Deadline: the date the appeal must arrive.
- Route: the form, portal, fax number, email address, or mailing address the plan requires.
- Reason: the exact service or payment denied and the reason given.
CMS's coverage-appeals guidance gives consumers 180 days after receiving a denial to file an internal appeal. Submit earlier when you can, and use the deadline printed on the notice for your case.1
Ask for an urgent appeal when waiting could cause harm
If the standard timeline could seriously jeopardize the person's life, health, or ability to regain maximum function—or a clinician says waiting would cause severe pain that cannot be adequately managed—ask the plan for an expedited appeal. In an urgent situation, an internal appeal and external review may be started at the same time. If there is immediate danger, call 911.1
Step 1: turn the denial into one answerable question¶
Ask: What exact plan rule or clinical criterion did the plan say was not met?
The denial notice should identify the claim and explain the reason. Depending on the decision, it should also identify relevant diagnosis and treatment codes, the specific plan provision or standard used, and the scientific or clinical judgment behind a medical-necessity or experimental-treatment denial. You can request a copy of the internal guideline or criterion used in the decision at no charge.1
If the reason is unclear, call the number on the notice and ask:
- What exact criterion was not met?
- What plan provision, policy, or guideline did you use?
- Can you send me that criterion and the clinical explanation in writing?
- Which records or facts were missing from the first review?
Record the date, time, name, title, and substance of the call.
Step 2: ask the clinical team for focused evidence¶
Give the treating clinician the denial notice and the plan criterion. Ask whether the clinical record supports an appeal and whether the clinician can provide a letter or other information for the plan to consider. CMS specifically identifies a doctor's letter as information that may be submitted with an internal appeal.1
A focused clinician letter can address:
- the service, treatment, medication, or level of care being requested
- the diagnosis and relevant clinical history
- why the requested care is medically necessary for this person
- which facts in the record meet the plan's stated criterion
- why an alternative named by the plan is not appropriate, if that is clinically true
The clinician should make the clinical argument. The caregiver's role is to make sure the denial reason, plan criterion, and relevant records reach the clinician.
Step 3: build one complete appeal packet¶
Follow the plan's required form and process. Keep the original documents and send copies unless the plan explicitly requires otherwise.1
Include:
- the plan's appeal form or a short appeal letter
- the denial notice or EOB
- the plan provision, guideline, or criterion used in the denial
- the clinician's letter and medical records that address the disputed criterion
- any other supporting information you want the reviewer to consider
- an authorized-representative form if a caregiver, clinician, or advocate will file for the member
- a simple attachment list so the reviewer can see what was submitted
Keep a full copy of the packet, proof of delivery, and notes from every related call. CMS recommends retaining denial and EOB documents, information sent to the plan, representative forms, and dated call notes.1
Step 4: make the request easy to decide¶
Use the plan's language and keep the argument tied to its stated reason. A short structure is enough:
Decision being appealed: Identify the denied service, claim, or authorization.
Denial reason: Quote or closely summarize the plan's stated reason and criterion.
Why the decision should change: Point to the clinician's explanation and the specific attached records that address that criterion.
Requested action: Ask the plan to authorize the service or reprocess the claim.
Attachments: List every enclosed document.
Build the appeal from the plan's actual denial and criterion plus evidence reviewed by the treating clinician. An AI-generated summary is not a substitute for those documents.
Step 5: submit and track it¶
Send the packet through the route named in the denial notice before the deadline. Save the confirmation page, fax receipt, delivery record, or other proof. Ask the plan to confirm receipt and provide a reference number.
At the end of the internal appeal, the plan or issuer must provide a written decision. If it continues to deny the service or payment, that decision should explain how to request an external review.1
If the internal appeal is denied¶
An external review is performed by an independent third party through a state or federal process. Follow the final denial's instructions because the receiving organization depends on the plan and state. A standard external review must be decided as soon as possible and no later than 45 days after the request is received; an expedited review must be decided as soon as the medical situation requires and no later than 72 hours. If the independent reviewer overturns the denial, the plan or issuer must accept that decision.1
The member may appoint an authorized representative to help file the external review. A caregiver who is organizing or filing the case should use the authorization process described in the denial notice before filing or asking the plan to discuss someone else's claim.1
Get help with the process¶
The denial notice should identify any applicable consumer-assistance or ombudsperson service. A state Consumer Assistance Program may be able to help file an appeal or act on the member's behalf. You can also ask the plan's member-services team where to obtain its appeal criteria and authorized-representative form.1
An appeal is not a guarantee of coverage. The practical goal is narrower: meet the deadline, answer the plan's stated reason with the most relevant plan and clinical evidence, and preserve the next review option.
For broader help with insurance and healthcare-system navigation, see Legal & Navigation.