Appeal a denied health insurance claim and get it paid
A complete internal appeal filed with your insurer inside the 180-day ERISA window — claims file and plan document obtained, denial codes decoded, a physician-signed letter of medical necessity attached, statutory citations in place — plus a state external-review petition prepared in case the insurer upholds the denial.
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Included with every copy
- Your own copy — keep it forever
- Gets better over time — free updates included
- Run it on web and mobile
- Invite a partner to go through it with you — you share the same progress
- 5 knowledge checks to test what you've learned
- The playbook's community — ask questions, get additions, and see how other buyers improve it, right on the step
Who it's for
Patients and family caregivers in the U.S. holding a denied claim over $500 for an ER visit, surgery, imaging, or a specialty prescription — especially where the denial letter says “not medically necessary” or “out-of-network” and the balance is now the patient's responsibility. Fits readers who would rather spend a few evenings on paperwork than pay a patient advocate $125–$250 an hour. Requires comfort writing a letter and keeping copies of what you send.
About this playbook
When your insurer denies a claim and the balance lands on your doorstep, you have a federal right to fight it — and a deadline to meet. This guide walks you through the full internal-appeal process under ERISA: decoding the denial codes on your EOB, forcing the plan to hand over its own files, building a physician-signed case for medical necessity, and filing an appeal that cites the plan's own language and the law that binds it. You finish with your appeal filed inside the 180-day window and a state external-review petition ready if the insurer upholds the denial. It covers private employer and fully insured plans in all 50 states, including No Surprises Act protections for out-of-network emergency care. It does not cover Medicare, Medicaid, Tricare, or VA claims, and it is not legal advice.
What you'll do, step by step
Free preview — these steps are open to read in full before you buy.
Phase 1: Decode the denial and know your plan
0/4The reader gathers the denial paperwork, decodes the insurer's stated reasons into plain English, learns which law governs the plan, and starts the 30-day statutory clock on a claims-file and plan-document request.
- 45 min
- 30 min
- 20 min
Phase 2: Build your medical case
4 stepsPhase 3: Write the internal appeal
4 stepsPhase 4: File and manage the internal appeal
4 stepsPhase 5: Escalate to external review
3 stepsDetails
What you need first
The denial letter and Explanation of Benefits for the claim, with the claim number and policy number handy. The denial was received within the last 180 days (the ERISA appeal window). Access to the plan's Summary Plan Description or the benefits office. A printer, envelopes, and the ability to send certified mail (or access to the plan's online appeal portal). A treating physician willing to sign a letter of medical necessity. A claim under a private employer or fully insured plan — not Medicare, Medicaid, Tricare, or the VA.
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About the creator
I write playbooks about paperwork, applications and dealing with public institutions. Step by step, in the order things actually happen.
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