Receiving a denial from your health insurance provider can be frustrating — especially when you believe the service should be covered. The good news? You have the right to appeal, and in many cases, denials are overturned when patients take action.

This guide walks you through the two types of appeals (internal and external) and gives you the tools, sample letters, and tips you need to navigate the process confidently.

What Happens When a Claim Is Denied?

After a medical visit or procedure, either you or your healthcare provider submits a claim to your insurance company. In most cases, the insurer processes the claim and pays the bill. But sometimes, they'll deny the claim — either in part or in full — for reasons such as:

  • The service wasn't deemed medically necessary
  • You used an out-of-network provider
  • Incorrect coding or missing documentation
  • Prior authorization was not obtained

When this happens, you don't have to accept the denial — you can appeal it.

Step 1: File an Internal Appeal

An internal appeal is your formal request for your insurance provider to reconsider their denial. You have up to 180 days (6 months) from the date of denial to file this type of appeal.

How to Start an Internal Appeal:

  • 📞 Contact Customer Service: Use the number on the back of your insurance card to ask how to file an appeal.
  • ✍️ Submit a Written Request: Include your:
  • Full name
  • Insurance ID number
  • Claim number
  • Date of service
  • Reason for your appeal

You can also include:

  • A letter from your doctor explaining why the service was medically necessary
  • Any supporting medical records, prescriptions, or test results

Sample Appeal Letter Template:

Your Name
Your Address
Date

Appeals Department
[Health Plan Name]
[Address]

Re: Internal Appeal Request
Plan ID#: [Plan Number]
Claim #: [Claim Number]

To Whom It May Concern,

I am requesting an internal review of the denial of coverage for services provided by [provider name] on [date]. The denial reason was [state the reason], but I believe this service is covered under my policy and was medically necessary.

[Insert short, factual explanation of why the service was needed. Reference policy language or attach supporting documents.]

Please find attached the relevant documents for your review. I can be reached at [phone/email] for any questions. Thank you for your timely attention to this matter.

Sincerely,
[Your Signature]
[Your Name]

⚡ Urgent Needs?
If your health, life, or ability to function is at risk, you can request an expedited review, which must be completed more quickly — often within 72 hours.

Step 2: If Denied Again, Request an External Review

If the internal appeal does not resolve the issue, you can move on to an external review, where a neutral third party evaluates your claim.

Key Points About External Reviews:

  • Must be requested within a specific timeframe (usually 4 months) after receiving the internal appeal decision
  • Conducted by an independent review organization (IRO) — not your insurance company
  • Their decision is binding — if they overturn the denial, your insurer must pay for the service

How to Request an External Review:

  • Review the instructions in your internal appeal denial letter
  • Submit any new supporting documents (medical records, letters, prescriptions)
  • Your state insurance department usually oversees the external review process

📍 Need Help?
Visit naic.org to find your state's insurance regulatory agency.

Medicare and Medicaid Appeals

If you are covered by Medicare or Medicaid, your appeal rights are slightly different:

  • Medicare: Call 1-800-MEDICARE or visit medicare.gov for help
  • Medicaid: Contact your state's Medicaid office for local rules and appeal processes

Pro Tips for a Successful Appeal

✅ Keep Everything Documented

  • Save denial letters, EOBs (Explanation of Benefits), and all correspondence
  • Keep copies of any bills, receipts, and supporting materials you submit

📝 Track Communication

  • Record the date, time, and names of everyone you speak with
  • Note what was discussed and any deadlines given

🔁 Follow Up Regularly

  • If you haven't received a response by the deadline, call your insurer and ask for a status update
  • Be polite but assertive — your health is worth it

You Have the Right to Fight Back

Insurance companies don't always get it right. But by understanding your rights and following these steps, you can challenge unfair denials and potentially save thousands of dollars.

Appealing a denied health insurance claim may take some time and persistence, but the results are often worth it — especially when you're fighting for medically necessary care.