Appealing a Claim Denial

Insurers have to tell you why they’ve denied your claim, and they have to let you know how you can dispute their decisions. Your insurer must notify you in writing and explain why a claim was denied:

  • Within 15 days if you’re seeking prior authorization for a treatment
  • Within 30 days for medical services already received
  • Within 72 hours for urgent care cases

You have 180 days (6 months) to file an appeal after receiving notice that your claim was denied.

Did you know…? If your employer is a Lumity client, our support team can provide guidance on claim denials. Not a customer? Many states offer Consumer Assistance Programs to help you navigate health insurance problems.

What you can do

Start by asking your insurance carrier to reconsider their decision. To do this, you’ll need to: 

1. Understand why your claim was denied

  • Your explanation of benefits (EOB) should provide the information you need. If there’s anything you don’t understand, call your insurance carrier. 
  • Inspect your EOB for any clerical errors. Sometimes a claim is denied due to something that can be corrected without going through an appeal process (like a typo on your name, insurance ID number, or a wrong date of service).
  • If you got a "lack of information" denial, then the insurance carrier didn’t have enough information to make a decision. Work with your medical provider to quickly get any additional information so it doesn’t turn into a real denial.

2. Gather your supporting evidence

  • Additional, relevant information about your health history may help get a claim approved.

3. Submit an appeal

  • Make sure you follow your insurance carrier’s appeal process. Instructions should be provided on your EOB, or you can call and ask. 
  • Submit an internal appeal. If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal.
  • You have the right to an external, third party review if your internal appeal is denied.

4. Keep good records

  • Hold onto your Explanation of Benefits and/or medical receipts
  • Keep originals or copies of all the forms/paperwork related to your claim and the denial
  • Take detailed notes on any phone conversations you have with your insurance company or doctor. Include the day, time, name, and title of the person you talked to and details about the conversation.

Internal Appeal

If your insurance carrier denies your claim, you can ask your insurance company to reconsider their decision. This service is provided at no cost to you. 

To file an internal appeal, you’ll need to:

  • Complete all forms required by your health insurer. Or you can write to your insurer with your name, claim number, and health insurance ID number.
  • Submit any additional information that you want the insurer to consider, such as a letter from the doctor.
  • File your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.

If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal.

How long does an internal appeal take?

Your insurance carrier must complete the internal appeal: 

  • Within 30 days for a service you haven’t received yet
  • Within 60 days for a service you’ve already received 

At the end of the internal appeal process, your insurance carrier must provide you with a written decision. If your insurance company still denies your claim, you can ask for an external review.

External Review

You have the right to appeal an insurance carrier’s final decision and have it reviewed by a third party. Some carriers don’t charge for this service. If you are charged, the Affordable Care Act limits the amount you can be charged to $25. 

  • You must file a written request for an external review within 60 days of the date your insurance carrier sends you their final decision. (Some plans may allow more time)
  • You may appoint a representative (such as your doctor or medical professional who knows about your medical condition) to file an external review on your behalf.
  • The external review issues a final decision. The review may uphold your carrier’s decision or decide in your favor.
  • Standard external reviews are decided as soon as possible, but no later than 60 days after the request was received.

Related reading:

Precertification for Medical Services
Prior Authorization for Prescription Drugs

Resources and references: Consumer Assistance Program How to Appeal an Insurance Company Decision Appealing Health Plan Decisions

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