Denied by Your Health Insurer? How to Appeal, State by State

Federal rules, at 45 CFR 147.136, require a plan to tell you in writing why it denied the claim, how to appeal, and how to ask for an external review once the internal appeal is over, and to do it "in a culturally and linguistically appropriate manner," which means a notice you can get in your language. The letter also names the deadline. Put that date on a calendar before you do anything else, because the clock runs from when you received the notice, and a missed internal deadline forfeits the external review.

Two more things to pull from the letter. The denial code and the plan's stated reason (not medically necessary, experimental, out of network, no prior authorization, not a covered benefit) decide which argument wins. And if the plan relied on a clinical policy or guideline, ask for it by name; you are entitled to the information the plan used, free, and your doctor can answer it point by point.

HealthCare.gov states the rule plainly: "You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied." File in writing, keep a copy, and send it the way the letter says. The plan must decide "within 72 hours for urgent care cases," within 30 days if you are appealing a denial of care you have not yet received, and within 60 days for care you already got.

What goes in it: a one-page letter that names the claim number, the date of service, the plan's stated reason, and why it is wrong, plus a letter of medical necessity from the treating clinician that uses the plan's own criteria as its headings. If the denial says a drug or procedure is experimental, attach the clinical guideline or FDA label that says otherwise. If it says out of network, attach the referral or the proof that no in-network clinician was available. Ask the clinic; most have a staff member who writes these every week.

One protection people miss: if the plan is cutting off treatment you are already getting, the regulation requires plans "to provide continued coverage pending the outcome of an appeal." Say in the first line of the appeal that you are requesting continued coverage during the appeal.

If the internal appeal fails, you can take the decision outside the company. The federal rule allows an external review request "within four months after the date of receipt of a notice of an adverse benefit determination." It applies to any denial that involves medical judgment, to denials calling care experimental or investigational, and to cancellations of coverage for alleged misstatements on your application. HealthCare.gov: "Your insurer is required by law to accept the external reviewer's decision." Standard decisions come "no later than 45 days after the request was received"; expedited ones in "no later than 72 hours, or less, depending on the medical urgency of the case."

The review is run either by your state insurance department or, where the state has not set one up that meets federal standards, by the federal HHS-administered process, which takes requests by phone at 1-888-866-6205 and by fax at 1-888-866-6190. We opened each state's own page on October 27 and 28, 2026 and recorded what it says. Where a state sets a shorter deadline than four months, the table shows the state's number; it is the one that binds a state-regulated plan.

If your coverage comes from a large employer that pays claims itself (a self-funded plan, which most big-company plans are), state insurance departments have no authority over it. The internal appeal and the external review still exist, under the same federal rules, but the external review runs through the federal process or an independent review organization the plan contracts with, and the Department of Labor is the regulator. Your summary plan description says which kind of plan you have; the human resources office must give you a copy on request.

Medicaid denials follow a different path with a stronger protection. Under 42 CFR 431.221, the state "must allow the applicant or beneficiary a reasonable time, not to exceed 90 days from the date that notice of action is mailed, to request a hearing." Some states give fewer days, and the table shows your state's number. If you are in a Medicaid managed care plan, you usually appeal to the plan first and then to the state.

The protection: under 42 CFR 431.230, if you request the hearing before the date the action takes effect, "the agency may not terminate or reduce services until a decision is rendered after the hearing," with narrow exceptions. The state must then decide "ordinarily, within 90 days" of receiving your request, and within three working days for expedited appeals of denied services where your health requires it. Ask for the hearing in writing, keep proof of the date, and say on the request that you want services continued.

Original Medicare appeals start with the date printed on your Medicare Summary Notice: "You must file your appeal by the date in the MSN." The Medicare Administrative Contractor generally answers within 60 days, and there are five levels, up to federal court. In a Medicare Advantage plan you "must file an appeal within 65 days from the date on the initial denial notice sent by your plan," the plan answers in 30 days (care not yet received), 60 days (payment) or 72 hours (fast appeal), and if it upholds the denial "they'll automatically forward their reconsideration decision to an Independent Review Entity." The HHS Office of Inspector General found in 2022 that "among the prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules," which is the case for appealing in one sentence.

Every state insurance department runs a consumer line, listed under the state name in the table; it will tell you which review applies and send the form. State Health Insurance Assistance Programs (SHIPs) counsel Medicare beneficiaries free. Many states fund a consumer assistance program that will file the appeal with you. If a denial is for care you need now, say the word "expedited" to every person you speak to and ask your clinician to call the plan's physician line; a peer-to-peer call resolves many urgent denials in a day.

The rules above apply to everyone, and the difference is who uses them. A denial letter is written to be put down, and the people with the least time, the least paid leave and the longest history of being told no by the health system are the ones most likely to put it down. The deadlines in the table are the whole game: an appeal filed on day 179 has the same rights as one filed on day one. Keep the letter, mark the date, and file.