Nivellark · U.S. patient guide

How to appeal a health insurance decision

If a health plan denies a service or payment, you can ask it to review the decision. Many private plans have an internal appeal process, and some decisions may qualify for review by an independent reviewer. The steps, deadlines, and available reviews depend on your plan, type of coverage, state, and the reason for the denial.

Official sources reviewed October 19, 2026

If the situation is urgent

If waiting for a standard review could seriously affect your health, contact your clinician and plan promptly and ask how to request an expedited appeal. The qualifying conditions and process vary. Use the urgent-review instructions in your notice.

Official sources: HealthCare.gov: Internal appeals; Centers for Medicare & Medicaid Services (CMS): Appealing health plan decisions

Steps to take after a denial

  1. Read the denial notice carefully

    Keep the full denial letter and any Explanation of Benefits (EOB). Look for the reason for the decision, the service or claim involved, how to appeal, where to send it, and the deadline. The date you received the notice may matter.

    If something is unclear, call the number on the notice or your insurance card. Ask the plan to explain the reason, the exact filing deadline, and whether another internal review or an outside review may be available for your type of coverage.

    Official sources: HealthCare.gov: How to appeal an insurance company decision; Centers for Medicare & Medicaid Services (CMS): Appealing health plan decisions

  2. Gather the records that relate to the decision

    Read the plan’s appeal instructions and coverage materials, including the Summary Plan Description (SPD) if your employer plan has one. Ask the plan how to get the records and criteria it relied on. Ask your provider for relevant visit notes, test results, bills, or other records.

    • Keep the denial notice, EOB, plan materials, bills, and related medical records together.
    • Check names, dates, service codes, and other details for errors.

    Official sources: Centers for Medicare & Medicaid Services (CMS): Appealing health plan decisions; Centers for Medicare & Medicaid Services (CMS): Action plan: Health insurance plan denied a claim; U.S. Department of Labor (DOL): Filing a Claim for Your Health Benefits

  3. Ask your provider about supporting information

    If a clinician is involved, ask whether they can explain why the requested care is medically appropriate and address the reason in the denial. If a bill or code may be wrong, ask the provider’s billing office to review it. You decide what information to submit.

    Official sources: HealthCare.gov: Internal appeals; Centers for Medicare & Medicaid Services (CMS): Action plan: Health insurance plan denied a claim

  4. File the internal appeal the way your plan requires

    An internal appeal asks the plan to reconsider its own decision. Use the form, portal, address, or other method in your notice. Identify the decision you are appealing, explain briefly why you disagree, and include relevant supporting documents. Ask whether your representative needs to be formally authorized.

    Submit it by the deadline in your notice. Keep a copy of everything you send and proof of when and how it was submitted. If the case is urgent, use the plan’s expedited-review instructions and ask your provider to help explain the urgency.

    Official sources: HealthCare.gov: Internal appeals; Centers for Medicare & Medicaid Services (CMS): Appealing health plan decisions

  5. Track the response and read the next notice

    Write down the date you filed, any confirmation number, and follow-up calls. Respond promptly if the plan asks for more information. When the plan sends its decision, read the whole notice: it should explain the result and any next review step that applies to your coverage.

    Official sources: HealthCare.gov: How to appeal an insurance company decision; HealthCare.gov: Internal appeals

  6. Check whether an external review is available

    For some denials, you may be able to ask an independent reviewer outside the plan to review the decision. Eligibility, who handles the review, whether another internal step is required, and the deadline vary. Follow the final denial notice and the process for your plan and state; do not assume every denial qualifies.

    Official sources: HealthCare.gov: External review; Centers for Medicare & Medicaid Services (CMS): Appealing health plan decisions

First identify what kind of decision you received

This guide focuses on a health plan’s decision about a service or payment. Marketplace eligibility or financial-help decisions use a separate appeal process. Medicare and Medicaid have program-specific appeal routes; for a Medicaid eligibility denial, fair-hearing steps vary by state. Use the official instructions for your program and the notice you received.

Official sources: HealthCare.gov: Appealing a Marketplace decision; Medicare.gov: Filing an appeal; Centers for Medicare & Medicaid Services (CMS), Medicaid.gov: Understanding Medicaid fair hearings

Where to ask for help

CMS lists state Consumer Assistance Programs and other resources that may help people understand a health plan appeal. Your state insurance regulator may also direct you to the right process. For a private-sector job-based plan, the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) has information about employee health-benefit claims. If you have Medicare, Medicare points to your State Health Insurance Assistance Program (SHIP) for free local counseling.

Official sources: Centers for Medicare & Medicaid Services (CMS): Appealing health plan decisions; U.S. Department of Labor (DOL): Filing a Claim for Your Health Benefits; Medicare.gov: Filing an appeal

Official sources

Looking for a plain-language explanation of denial-letter terms? Read the denial-letter glossary. For questions about Nivellark’s administrative case tools, read the denied-therapy appeal FAQs. For free official appeal help, browse the appeal-support resource directory.