My claim was denied
My appeal was turned down — is there another step?
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Usually yes. After a final internal denial, most private plans must offer an external review by an independent reviewer, and Medicare has five appeal levels; your letter names the next step and the deadline.
What to do
- Read the final denial letter for the words 'final' and 'external review', and note the deadline. Ask the plan whether any internal appeal is left; some job-based plans have two levels.
- Request the external review the way the letter says. Send your evidence plus anything new, such as a letter from your doctor.
- Ask for an expedited (fast) review if waiting could seriously harm your health. Fast reviews are decided within 72 hours or less.
- If the plan will not tell you how to request external review, contact your state insurance department. With Medicare, follow the next level named in your letter.
What to say
This is the plan's final internal decision, correct? I want to request an external review. Can you tell me exactly how to file it and the deadline?
Ask before the deadline on the letter; it is usually 4 months, but use the date printed.
What to watch out for
This is a sensitive stepSmall details here can change the outcome, and some mistakes are hard to undo. We highly recommend a free 15-minute call with us before you decide.
Sending the same appeal letter again to the same plan. The next step is a different reviewer, so add the doctor's letter or records you did not have the first time.
Better done together
We’re here to help
A second no isn't always the end. Each level of appeal has its own rules, deadlines and format. We help you work out which step comes next and what to send, so the next reviewer sees what the last one missed.
Every situation is different, and these are sensitive moments, so we look at yours with care. We often see what others miss, and we never take commissions from insurance companies: the only thing we are working for is what is right for you.
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The rule behind it
The Affordable Care Act gives most people with private plans the right to an external review by an independent reviewer after the plan's final internal denial, usually requested within 4 months, and the plan must follow the reviewer's decision. It covers denials based on medical judgment, such as 'not medically necessary' or 'experimental'. Original Medicare and Medicare Advantage generally have five appeal levels, and each decision letter explains how to reach the next one.
Sources
- HealthCare.gov — External review
- Medicare.gov — Appeals
- Cornell LII — 29 CFR 2560.503-1 (group plans: no more than two appeal levels)
- Your final denial letter
Amanda Alcodia
Education, not medical, legal or insurance advice.
Useful next steps
Start with the free Kit. If your situation needs a person, the intro call is free too.