They denied my claim — how do I appeal?

A denial is not a verdict. It's the opening position. Insurers deny claims routinely, including claims they will ultimately pay, and a meaningful share of appeals succeed — especially the ones that go all the way to independent external review. Most people never appeal. That's what the system is built on.

Here's how to do it properly.

Step one: get the denial in writing

You are entitled to a written explanation that states the specific reason and the specific plan provision it relies on. Not "not medically necessary" — the actual clause. Request it if you only got a phone call, and note the reference number.

Read it for what kind of denial it is, because each has a different counter:

• Not medically necessary → you need a letter of medical necessity and supporting guidelines.
• Excluded benefit → the fight is over plan language, or over how the claim was coded.
• No prior authorization → often fixable retroactively, especially if the clinic dropped it.
• Out of network → ask about a network gap exception if no in-network provider offers the service.
• Coding or administrative error → the most common and the easiest. Your clinic's biller can often resolve it with a phone call.

Always call the clinic billing office first. A real share of "denials" are typos.

Step two: the internal appeal

Under the federal rules that govern most plans, you generally have 180 days from the denial notice to file an internal appeal, and the insurer then has roughly 30 days to decide for care you haven't received yet, or 60 days for care already provided. If waiting would seriously jeopardize your health, you can request an expedited review.

What to include:

• A cover letter with your name, member ID, claim number and the denial date, stating plainly what you want approved.
• A letter of medical necessity from your doctor. This is the heart of it. It should name your diagnosis, your specific clinical history, what's been tried, why this service is medically indicated for you, and what happens without it — and it should cite professional guidelines (ASRM, ACOG) by name.
• The relevant plan language, quoted, if you're arguing the denial misreads it.
• Supporting records: test results, prior treatment notes, referral letters.
• Any state mandate that applies, quoted, if your plan is fully insured.

Send it in a way that creates proof of delivery, and keep a copy of everything.

Step three: external review, where the leverage is

If the internal appeal fails, you can request an independent external review by reviewers who don't work for your insurer. Their decision is binding on the plan. This is the part most people never reach and it's where the real power sits.

Standard external reviews are decided within 45 days. Urgent ones move much faster, and in a genuinely urgent situation you can go straight to expedited external review without finishing the internal appeal — a decision must come as fast as your condition requires, and no later than 72 hours.

Your denial letter must tell you how to request external review. If it doesn't, ask, and contact your state insurance department.

Keep a paper trail from day one

Start a single document. Every call: date, time, who you spoke to, what they said, and the reference number. Every letter: what you sent and when. Save the denial letters and your plan documents in the same place.

This feels excessive right up until the moment it wins your appeal. "On March 4th, reference number 88214, your representative Denise confirmed this was covered" is the sentence that ends arguments.

Who else can help

• Your clinic's financial counselor or billing specialist. They appeal for a living. Ask who handles appeals and work with that person by name.
• Your doctor. A peer-to-peer review, where your physician talks directly to the insurer's medical director, resolves a lot of medical-necessity denials. Ask for one.
• HR or benefits, especially if self-funded.
• Your state insurance department, for fully insured plans. They regulate the insurer, and a complaint gets attention.
• The Department of Labor, for self-funded ERISA plans.
• RESOLVE, which has advocacy resources and knows the mandate landscape state by state.

The honest part

This is exhausting, and you are being asked to do it at the worst possible time. Two things help. Appeal anyway, because the odds are better than they feel and the system counts on you not bothering. And hand off what you can — your clinic's biller, your partner, HR — because none of this has to be done alone, and being the patient is already a full-time job.