How long does an insurance appeal take?

For standard non-urgent claims, your insurer must respond to your internal appeal within 30 days. For urgent care denials, they have 72 hours. External review decisions typically take up to 45 days — or 72 hours for expedited requests. Your denial letter will show the specific deadlines that apply to your plan.

What is an external independent review?

An external review is where a neutral third party — a board-certified physician in the relevant specialty — reviews your insurer's denial. They are not affiliated with your insurer. Their decision is binding. If they say pay it, your insurer pays it. For plans subject to ACA rules, this process is free.

Can my insurer deny my appeal again?

Your insurer can uphold the denial on internal appeal. That is why the external review process exists. Once an external reviewer rules in your favor, the insurer cannot override that decision. If the external reviewer also upholds the denial, you still have options — regulatory complaints, ERISA civil action, or bad faith claims depending on your plan type.

What if my doctor supports the treatment but insurance still denies?

This is a strong appeal case. External reviewers must consider your treating physician's opinion — and when treating doctors document the medical necessity thoroughly, external review outcomes favor patients significantly more often. Make sure your doctor writes a detailed letter, not just a brief note. Specifics win.

Is there a cost to file an external review?

For ACA-regulated plans, external review is free. Some states allow a small filing fee — usually $25 or less — which gets refunded if you win. Under ERISA, employees can also bring a civil action in federal court if the plan wrongly denies benefits. Many attorneys take ERISA cases on contingency.

What if my appeal deadline has passed?

Check whether the deadline was actually missed or whether you received inadequate notice of your appeal rights — that can toll the deadline. Some states allow extra time for good cause. If the denial involves ongoing treatment, a new denial of a new service triggers fresh appeal rights. Complaints to your state insurance commissioner also have separate and often longer filing windows.

Insurance Denied Your Claim? Here Is How to Appeal and Win

Your insurer sent you a denial letter. Maybe it says 'not medically necessary.' Maybe it says 'out-of-network.' Maybe it barely explains anything at all.

It feels final. It is not.

Under federal law, you have the legal right to appeal — and appeals work far more often than most people realize. The process takes effort. But the law is built for exactly this situation.

“In 2022, insurers reversed more than 40% of denied claims when patients appealed to external independent reviewers.”

Why Insurers Deny Valid Claims

Most initial claim reviews are automated. A system flags your claim based on codes, not on your actual medical situation.

Common denial reasons: 'not medically necessary' (often an algorithm, not a doctor), missing prior authorization, out-of-network provider, or a treatment labeled 'experimental' even when doctors use it routinely.

The denial is not the final word. It is the beginning of the process the law built for you.

Regulation Citation

Affordable Care Act — Appeals and External Review Rights

ACA § 2719; 45 CFR §§ 147.136, 147.138; ERISA § 503

You have the legal right to appeal any denied health insurance claim. Insurers must provide at least one internal appeal and then an external independent review. The external reviewer's decision is binding on your insurer — they must pay if the reviewer says so.

Step 1 — File Your Internal Appeal

Your first move is an internal appeal — you ask your insurer to look again. You typically have 180 days from the denial notice to file. Check your denial letter for the exact deadline. Do not miss it.

Your appeal should include: a copy of the denial letter, a letter from your doctor explaining why the treatment was medically necessary, relevant medical records, and clinical guidelines from a medical society supporting the treatment.

Call member services to confirm the correct address. Send it certified mail. Keep copies of everything.

How to Write an Appeal Letter That Works

Open with one clear sentence: 'I am formally appealing the denial of claim [number] dated [date].'

Then explain why the denial is wrong. Use your doctor's medical judgment. Reference your plan's own coverage terms. Pull clinical guidelines from organizations like the American College of Physicians that support the treatment as standard of care.

Include the specific CPT code or procedure that was denied
Include your treating physician's letter — with their license number
Include peer-reviewed guidelines or medical society recommendations
Include documentation of any prior authorization your doctor requested
Include a copy of your Summary of Benefits and Coverage
End with a response deadline — 'Please respond within 30 days'

Step 2 — Request External Independent Review

If your internal appeal is denied, you are entitled to an external review. An independent reviewer — not connected to your insurer — examines the denial and makes a final, binding decision.

This is free to you. If the external reviewer says the claim should be paid, your insurer must pay it. That is the law.

Regulation Citation

External Review Rights

ACA § 2719; 45 CFR § 147.138

After exhausting internal appeals, you can request external review from a certified independent organization. For urgent situations, you can skip internal appeals and go straight to expedited external review. The reviewer's decision is legally binding on your insurer.

ERISA Plans vs. Fully Insured Plans — The Difference Matters

If your insurance comes through a large employer, the plan is probably self-funded under ERISA. That means your state insurance commissioner has limited power over it — but federal ERISA protections apply.

If you bought your plan on the marketplace or through a small employer, it is fully insured. Both state and federal law apply. You have more regulators on your side.

Check your Summary Plan Description. If it says 'self-funded' or 'self-insured,' ERISA governs. This matters when you decide where to file complaints.

Filing a State Insurance Complaint

If your plan is fully insured — not ERISA — file a complaint with your state insurance commissioner at the same time you appeal. Do not wait for the appeal to finish.

State regulators have real enforcement authority over fully insured plans. A filed complaint creates a formal record. Sometimes regulators intervene directly.