My claim was denied
The ER visit was denied as "not an emergency" — what now?
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You can appeal. Federal rules say emergency care is judged by what a reasonable person would think at the time, not by the final diagnosis. Your symptoms when you walked in are the evidence.
What to do
- Request the ER records, including the triage note (the nurse's first assessment) that lists your symptoms on arrival.
- Write down what you felt, when it started, and why you thought it could not wait, in plain words.
- Quote the prudent layperson standard in your appeal: a person with average knowledge of health would have thought this was an emergency.
- Ask the ER doctor's group for a short letter saying the symptoms called for an emergency evaluation.
- File the internal appeal by the deadline on the letter, and ask for external review if the plan says no again.
What to say
I'm appealing this denial under the prudent layperson standard. My symptoms when I arrived were [describe them], and a reasonable person would have thought this was an emergency.
Fill in your actual symptoms; the standard is about what you knew then, not what the tests found later.
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.
Letting the final diagnosis do the talking. 'It turned out to be indigestion' is not the question; the question is whether chest pain at that moment looked like an emergency to a reasonable person.
Better done together
We’re here to help
An ER denial can feel like being told you shouldn't have gone. We help you explain the symptoms as they were at the time, gather the right records, and put the appeal together.
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
Federal rules require most private plans to cover emergency care under the prudent layperson standard: whether a person with average knowledge of health and medicine would have expected serious harm without immediate care. The No Surprises Act, in effect since January 2022, adds that emergency care must be covered without prior authorization and at in-network cost sharing, even at an out-of-network ER. Your plan's Evidence of Coverage repeats these rules in its own words.
Sources
- 45 CFR 147.138 — Emergency services, prudent layperson standard (Cornell LII)
- CMS — No Surprises Act: what consumers need to know
- HealthCare.gov — Internal appeals
- HealthCare.gov — External review
- Your denial letter and your ER triage note
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.