Health
How to appeal a denied insurance claim
Denials are appealable through a defined process, a meaningful share are overturned, and the deadlines are strict.
A denial notice has to state the reason and explain how to appeal. Reading that reason carefully is the first step, because a denial for a coding or administrative error is a different and much simpler problem than one on medical necessity.
The first stage is an internal appeal to the insurer, with a deadline on the notice. If that fails, most plans are subject to external review by an independent body whose decision binds the insurer. There is an expedited route where delay would jeopardise health.
What strengthens an appeal is documentation from the treating clinician explaining why the care was necessary, with reference to the plan's own criteria where possible. Many clinicians' offices do this routinely and will help if asked.
Every state has a department of insurance that takes complaints, and many run a consumer assistance programme that will help with an appeal directly. Those services are free.
What to do next. Note the appeal deadline on the denial, ask your clinician for a letter of medical necessity, and contact your state's insurance consumer assistance programme.
studentaid.gov outranks this page. Rules, figures and dates change
between academic years. This is written to help you read the official sources, not to
stand in front of them. Start there.
Nothing here is a determination. We cannot tell you what you qualify
for, and no website can. The programme and the office that runs it decide that, after
you apply.
Still have a question?
Describe what you are trying to work out and a member of the team will answer, or direct you to the office that makes the decision.