Appeals
The 180-day clock on an insurance denial is not optional
Internal appeal, external review, and the deadlines that actually matter.
If an insurer denies a claim you think should be covered, you have the right to ask them to look again. The right comes with deadlines, and the deadlines are short enough that people miss them while gathering documents.
The sequence
- Internal appeal. Usually within 180 days of the denial notice. Ask the insurer to reconsider.
- A second level, if your plan has one.
- External review. An independent reviewer decides, usually within 4 months of a final denial. Standard decisions often come within about 45 days; urgent ones faster.
The insurer has to accept the external reviewer's decision. That is the part people do not realize: the independent reviewer is not advisory.
Fix it before you appeal it
In our own case the agent filed zero formal appeals. The denials were administrative and were cleared by fixing the underlying record. An appeal is a tool, not a reflex, and it is much slower than a phone call and a corrected submission.
What to gather
- The denial letter and the reason code.
- The EOB.
- Your coverage dates for the date of service.
- Reference numbers from every call you have made.
- A letter from your doctor if the denial is about medical necessity.
Ask the insurer for the plan provision and the clinical criteria they used. They have to give you the rule they applied, and seeing it often tells you what the appeal needs to address.
Deadlines and procedures vary by plan, especially for employer self-funded plans. Check your plan documents, and Medicare has its own five-level process.