Understanding Your Appeal Rights

Your Right to Appeal

When your insurance denies a claim or you believe you've been billed incorrectly, you have legal rights to challenge those decisions. Understanding these rights empowers you to fight for fair treatment.

Federal Appeal Rights

Under the ACA (Affordable Care Act)

All health plans must provide:

• Clear denial notices with reasons
• At least one level of internal appeal
• External review by independent third party
• Coverage during appeal for ongoing treatments

ERISA Plans (Employer-Sponsored)

If you have employer insurance:

• Written explanation of denial required
• At least one level of internal appeal
• 180 days to file initial appeal
• External review available for most denials

Medicare Appeals

Five levels of appeal available:

1. Redetermination by Medicare contractor
2. Reconsideration by Qualified Independent Contractor
3. Administrative Law Judge hearing
4. Medicare Appeals Council review
5. Federal court review

Timeframes to Know

Your Deadlines

Type	Typical Deadline
Internal appeal	180 days from denial
Urgent internal appeal	72 hours (expedited)
External review request	4 months from final internal denial

Insurance Company Deadlines

Type	Response Time
Standard internal appeal	30 days
Pre-service appeal	15 days
Urgent appeal	72 hours
External review	45 days (standard)

Internal vs External Appeals

Internal Appeal

What it is: Review by your insurance company

Process:

1. Submit written appeal
2. Different reviewer examines claim
3. Insurance makes new decision
4. You're notified in writing

Pros:

• Faster resolution possible
• Less formal process
• Free to file

Cons:

• Same company makes decision
• May uphold original denial
• Must complete before external

External Appeal

What it is: Review by independent third party

When available:

• After exhausting internal appeals
• For medical necessity denials
• For coverage disputes
• For rescissions of coverage

Process:

1. Request external review after internal denial
2. Independent Review Organization (IRO) assigned
3. IRO reviews medical records and policy
4. Binding decision issued

Pros:

• Independent reviewer
• Decision is usually binding on insurer
• Medical experts involved

Cons:

• Must complete internal first (usually)
• Takes additional time
• Limited grounds for further appeal

State Insurance Commissioner

What They Do

State insurance commissioners:

• Regulate insurance companies
• Investigate complaints
• Enforce insurance laws
• Provide consumer assistance

When to Contact

Reach out when:

• Insurance company isn't following the law
• Appeal deadlines aren't being met
• You're being treated unfairly
• You need help navigating the process

How to File a Complaint

1. Find your state's insurance department website
2. Locate the complaint form
3. Include all documentation
4. Describe the issue clearly
5. Submit and track your complaint

Expedited Appeals

When Available

Request expedited review when:

• Delay would seriously jeopardize life or health
• Immediate treatment decision needed
• Urgent care being delayed

Timeline

• Decision within 72 hours
• 24 hours for very urgent situations
• Notification by phone if possible

How to Request

• State that you need expedited review
• Explain the urgency
• Have doctor support the urgency
• Follow up immediately

Continuing Coverage During Appeal

Your Rights

While appealing, you may have the right to:

• Continue current treatment
• Receive coverage pending decision
• Not be charged during appeal

Important Notes

• Request continuation in writing
• You may owe costs if appeal fails
• Works for ongoing treatments, not new services

Know Your Plan

Every plan has specific procedures. Find yours by:

• Reading your Summary Plan Description
• Checking your Evidence of Coverage
• Calling member services
• Reviewing denial letters (should explain process)

Getting Help

Free Resources

• State insurance department
• Medicare SHIP programs
• Patient advocacy organizations
• Hospital financial counselors

Professional Help

• Patient advocates
• Medical billing advocates
• Healthcare attorneys (for large disputes)

Don't let fear of the process stop you from exercising your rights. Many denials are overturned on appeal.