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How to Appeal an Insurance Denial

Insurance denials are common and many are reversed on appeal. A denial does not mean the decision is final. If your health plan won’t pay for a medically necessary service, treatment, or prescription, you have the right to appeal that decision through your plan’s appeal process.

Table of Contents:

What Is an Insurance Denial?

An insurance denial occurs when your health plan refuses to pay for a healthcare service, medication, test, or procedure. This can be either before care is received (prior authorization denial) or after a claim is filed.

Common reasons for Insurance Denial

The service was deemed “not medically necessary”
Missing prior authorization
Incorrect billing or coding
Out-of-network care
Incomplete information

Many denials happen due to paperwork or administrative issues, not because the service shouldn’t be covered.

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How to Appeal

Step 1: Review Your Plan and the Denial

Before appealing, review:

Your denial notice
Your health plan documents
Your Summary of Benefits and Coverage (SBC)

Your denial notice should explain:

What was denied
Why it was denied
How to appeal
The deadline to appeal

Step 2: Check for Errors

Before submitting an appeal, review your records carefully.

Look for:

Incorrect patient information
Wrong service or diagnosis codes
Incorrect dates of service
Services that don’t match what you received

Sometimes correcting an error can resolve the denial without a full appeal.

Step 3: Submit an Internal Appeal

An internal appeal asks your insurance company to reconsider its decision.

Appeal Timeline

You usually have 180 days (6 months) from the date you receive the denial notice to file an appeal
Deadlines are strict — missing them may end your right to appeal

What to Include

Your appeal does not need to be technical or complicated. It should clearly state:

Which claim or service was denied
That you are appealing the denial
Why you believe the service should be covered

You may include any information you want the plan to consider, such as:

Medical records
A letter of medical necessity from your provider
Prior authorization approvals
Itemized bills
Relevant plan language

Here’s an appeal script:

NOTE: Most health plans require you to submit an appeal form or write a letter to start the appeal process.

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4) Keep Copies and Records

Good record-keeping is essential during the appeal process.

Keep copies of:

Your Explanation of Benefits (EOB)
The denial notice
Any appeal forms or letters you submit
All supporting documents
Notes from phone calls (dates, names, and what was said)

These records are important if you need to escalate your appeal.

5) Ask Your Provider to Help

Doctors and hospitals often assist with appeals.

You can ask your provider to:

Submit a letter of medical necessity
Correct billing or coding errors
Communicate directly with your insurance company
Provider support can significantly increase the chance of approval.

6) Track the Appeal Timeline

After submission:

Save confirmation numbers
Monitor deadlines
Follow up if you don’t receive a response

Health plans usually must respond within 30–60 days, depending on the type of service and whether the appeal is urgent.

7) Request an Independent (External) Review

If your internal appeal is denied, you may have the right to an independent external review by an Independent Review Organization (IRO).

When You Can Request an IRO

You may request an independent review after you’ve exhausted your plan’s internal appeal process if the denial was based on:
- Medical necessity
- Appropriateness of care
- Experimental or investigational treatment
Your health plan must:
- Provide you with the independent review request form
- Pay for the cost of the review
- Follow the IRO’s final decision

IRO Decision Timeline

Emergency treatment: decision within 5 days
Non-emergency treatment: decision within 20 days

Important Limitations

Health plans do not have to offer an IRO for services they do not cover at all
Certain plans (including Medicare, Medicaid, and some ERISA plans) may not participate in the IRO process

For more information about IROs, you can contact:

TDI Health and Workers’ Compensation Network Certification and Quality Assurance Office 1-866-554-4926

If Care Is Urgent

If your appeal involves urgent or ongoing treatment:

Ask about expedited appeals
Providers can often help request faster review
Do not delay necessary care without asking about emergency options

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Common Mistakes to Avoid

Missing appeal deadlines
Submitting an appeal without documentation
Assuming a denial is final
Paying a denied bill before appealing

How to Appeal an Insurance Denial

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