Appealing a Denied Health Claim: Internal Appeals and External Review

A denied claim is not the end of the conversation. Federal rules give you the right to ask your health plan to reconsider, and for many kinds of denials, the right to have an independent reviewer decide. HealthCare.gov puts it plainly: with external review, the insurance company "no longer gets the final say over whether to pay a claim."

The process has two stages. First comes an internal appeal, where the plan reviews its own decision. If the plan still says no, many denials can then go to external review by an independent organization. Both stages have deadlines, and missing one can end your options, so it helps to know the timeline before you start.

This guide covers the general federal rules for private health coverage as of October 2026. It is general information, not legal, insurance or medical advice. Plans, states and programs such as Medicare and Medicaid have their own procedures, so always follow the instructions in your own denial notice.

Start with the denial notice

Your denial notice is the map for your appeal. For job-based plans covered by the federal ERISA law, the U.S. Department of Labor (DOL) says the notice must give the specific reasons for the denial, point to the plan provision relied on, describe any extra information needed, and explain how to appeal. If the denial was based on medical necessity or an experimental-treatment exclusion, the plan must explain the clinical judgment behind it or offer that explanation free on request.

For plans that are not grandfathered under the Affordable Care Act, DOL says the notice must also include the denial code and its meaning, information about internal and external appeals, and consumer assistance contacts. You can ask for the diagnosis and treatment codes. You can also request, free of charge, copies of the documents and records relevant to your claim.

Read the reason carefully. A denial for missing paperwork or a coding error may be fixed with a phone call and a corrected claim. A denial for "not medically necessary" usually needs evidence from your doctor.

What you can appeal

HealthCare.gov lists common reasons a plan might deny a claim, all of which can be appealed:

• The benefit is not offered under your plan.
• The plan says your medical problem began before you joined.
• You used a provider or facility outside the plan's network.
• The plan says the service is not medically necessary.
• The plan considers the treatment experimental or investigational.
• The plan says you are no longer enrolled or eligible.
• The insurer is canceling your coverage back to your enrollment date, claiming you gave false or incomplete information.

Filing an internal appeal

As of October 2026, HealthCare.gov says you must file an internal appeal within 180 days (6 months) of receiving notice that your claim was denied. DOL says job-based plans must allow at least 180 days, and some plans allow longer, so check your plan documents.

To file, HealthCare.gov says to complete the forms your insurer requires, or write to the insurer with your name, claim number and health insurance ID number, and include any additional information you want considered, such as a letter from your doctor. A strong appeal usually does three things: it quotes the reason given in the denial, points to the plan language that supports coverage, and includes medical records or a letter from your doctor explaining why the care is needed for you.

Keep copies of everything: the Explanation of Benefits, the denial letter, your appeal and every document you send. Keep notes of each phone call, including the date, time, the name and title of the person you spoke with, and what was said. Send originals only where required, and use a delivery method you can track.

How long the plan has to decide depends on the type of claim. As of 2026, HealthCare.gov and DOL describe these limits:

• Care you have not received yet: a decision within 30 days.
• Care you have already received: a decision within 60 days.
• Urgent care: for job-based plans, DOL says as soon as possible and no more than 72 hours.

DOL notes that some plans require two levels of internal review; in that case, each level generally gets half the time. In urgent situations, HealthCare.gov says you can request an external review at the same time as your internal appeal. If a doctor with knowledge of your condition tells a job-based plan that a pre-service claim is urgent, DOL says the plan must treat it as urgent.

Asking for an external review

If the plan upholds its denial, its final decision must tell you how to request an external review. As of October 2026, HealthCare.gov says you must file a written request within 4 months after the date you receive the final denial.

External review is available for denials that involve medical judgment, denials based on a treatment being experimental or investigational, and cancellations based on claims that you gave false or incomplete information. Depending on your plan and state, the review is run under a state process or a federal process overseen by HHS, or by an independent review organization the plan contracts with.

HealthCare.gov describes these timelines and costs as of 2026:

• Standard external reviews are decided no later than 45 days after the request is received.
• Expedited reviews are decided no later than 72 hours after the request, or sooner if your condition requires.
• There is no charge under the HHS-administered federal process; under other processes, any charge cannot be more than $25 per review.
• Your insurer is required by law to accept the external reviewer's decision.

You can appoint a representative, such as your doctor, to file for you.

Extra points for job-based plans

ERISA's claims rules generally apply to private-sector employer plans, with exceptions for government plans and most religious organizations' plans. DOL says plans generally cannot charge you to file claims and appeals. On appeal, someone new must review your claim, not the original decision-maker or that person's subordinate, and must consult qualified medical professionals when medical judgment is involved.

If the final decision still denies your claim, DOL notes you may want legal advice about going to court, and that you normally must finish the plan's claims process first. You can contact DOL's Employee Benefits Security Administration (EBSA) at 1-866-444-3272 with questions about your rights.

Where to get help

You do not have to do this alone. HealthCare.gov says your state's Consumer Assistance Program can file an appeal for you, and that the Consumer Assistance Program or your state's department of insurance may be able to help with internal appeals and external reviews. CMS keeps a state-by-state map of these programs, and the NAIC keeps a directory of state insurance departments. For a complicated or high-dollar denial, a licensed attorney who handles health insurance matters can advise on your specific situation. If you have Medicare, which has its own appeals process, your State Health Insurance Assistance Program (SHIP) offers one-on-one counseling.

Key takeaways

• Read the denial notice first; it must state the reason and explain how to appeal, and you can request your claim file free.
• As of 2026, HealthCare.gov says to file an internal appeal within 180 days of the denial notice.
• Internal appeals are generally decided within 30 days for care not yet received and 60 days for care already received, faster when urgent.
• If the plan still says no, you generally have 4 months to request external review, and the insurer must accept the reviewer's decision.
• Keep copies and call notes, include your doctor's support, and ask your state's Consumer Assistance Program or insurance department for help.

Sources

• HealthCare.gov, How to appeal an insurance company decision
• HealthCare.gov, Internal appeals
• HealthCare.gov, External review
• U.S. Department of Labor, Employee Benefits Security Administration, Filing a Claim for Your Health Benefits
• CMS, Consumer Assistance Grants (state Consumer Assistance Programs)
• National Association of Insurance Commissioners, Insurance Departments
• Administration for Community Living, State Health Insurance Assistance Program (SHIP)