What to Do If Your Appeal is Denied

When the First Answer is No

An appeal denial isn't the end of the road. You have additional options to pursue, and many people succeed at higher levels of appeal. Here's what to do next.

Understand the Denial

Review Carefully

• Read the denial letter completely
• Identify specific reasons for upholding denial
• Note any new information considered
• Check for factual errors

Assess Your Options

Based on the denial, determine if you can:

• Address the specific reasons cited
• Provide additional evidence
• Escalate to the next level
• Pursue external review

Request External Review

What Is External Review?

An independent third party (Independent Review Organization or IRO) reviews your case and makes a binding decision.

When You Can Request

External review is available for:

• Medical necessity denials
• Coverage disputes
• Experimental/investigational denials
• After exhausting internal appeals

How to Request

1. File within 4 months of final internal denial
2. Submit to your insurance company's external review department
3. Include all supporting documentation
4. Request expedited review if urgent

What Happens

• IRO is assigned (you don't choose)
• Medical experts review your case
• They review same evidence plus any new information
• Decision typically within 45 days
• Decision is binding on insurance company

State Insurance Department

When to Involve Them

Contact your state's insurance commissioner when:

• Insurance isn't following proper procedures
• Deadlines aren't being met
• You believe laws are being violated
• You need help navigating the process

How to File a Complaint

1. Visit your state insurance department website
2. Complete consumer complaint form
3. Attach all relevant documents
4. Describe the issue clearly
5. Submit and track your complaint

What They Can Do

• Investigate the insurance company
• Mediate disputes
• Enforce insurance regulations
• Require policy compliance

What They Can't Do

• Practice medicine
• Override medical decisions
• Force coverage not in policy
• Represent you legally

Additional Appeal Levels

Second-Level Internal Appeal

Some plans offer additional internal reviews:

• Different reviewers examine case
• Opportunity to submit new evidence
• May involve peer-to-peer review
• Check your plan documents

Medicare Appeals

If you have Medicare, additional levels include:

• Administrative Law Judge hearing
• Medicare Appeals Council
• Federal court (for large amounts)

Legal Options

When to Consider Legal Help

• Large dollar amounts at stake
• Clear policy violations
• Bad faith by insurer
• Class action potential

Types of Legal Action

• Breach of contract claims
• Bad faith insurance claims
• ERISA violations (employer plans)
• State insurance law violations

Finding Legal Help

• Healthcare attorneys
• Insurance dispute lawyers
• Legal aid organizations
• Bar association referrals

Cost Considerations

• Many offer free consultations
• Contingency fees possible
• Compare potential recovery to costs
• Consider small claims court for small amounts

Patient Advocates

How They Help

Patient advocates can:

• Review your case
• Identify additional arguments
• Help with paperwork
• Navigate complex systems

Where to Find Them

• Hospital patient advocates
• Independent billing advocates
• Non-profit organizations
• Insurance company advocates

Alternative Resolution

Negotiate with Provider

If insurance won't pay:

• Ask for charity care programs
• Request financial hardship discount
• Negotiate payment plan
• Seek provider adjustment

Payment Plans

Even if you owe:

• Don't ignore the bill
• Negotiate affordable payments
• Protect your credit
• Document agreements

Don't Give Up

Statistics Show

• Many denials are overturned on appeal
• External review often favors patients
• Persistence pays off

Keep Records

• Document every interaction
• Save all correspondence
• Note names and dates
• Track deadlines

Escalate Appropriately

• Start with internal appeals
• Move to external review
• Involve regulators if needed
• Consider legal options as last resort

Checklist After Denial

• Review denial letter carefully
• Identify next available appeal level
• Determine if external review is available
• Gather additional evidence if possible
• Consider state insurance department complaint
• Evaluate legal options for significant amounts
• Explore negotiation with provider
• Document everything

A denial is just one decision. You have the power to continue fighting for what's right.