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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Who it's for
Patients and family caregivers in the U.S. with a denied health-insurance claim over $500 (ER visit, surgery, imaging, specialty prescription), able to write a letter and keep copies of what they send. Covers employer and fully insured plans; not Medicare, Medicaid, Tricare or VA.
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 stepFree preview
Only a sample is open: 3 of 18 steps can be read in full. The rest unlock when you buy.
Phase 1: Confirm Your Case and Appeal Deadline
3 stepsPhase 2: Build the Claims File and Medical Evidence
6 stepsPhase 3: Draft and File the Internal Appeal
2 stepsPhase 4: Track the Plan's Response
2 stepsPhase 5: Resolve the Appeal or Escalate to External Review
4 stepsPhase 6: Close Out the Case
1 step
Details
What you need first
The EOB and denial letter for the claim, your Summary Plan Description or insurance policy, and the treating physician's contact information. Not legal advice.
Tags
Common questions
Glossary
- EOB
- Explanation of Benefits — the insurer's statement showing what was billed, what it paid, and what it denied, with adjustment reason codes explaining why.
- ERISA
- The Employee Retirement Income Security Act of 1974 — the federal law governing most employer-sponsored group health plans, including the claims and appeals procedure at 29 CFR 2560.503-1.
- Self-funded plan
- A plan where the employer pays claims from its own assets and only hires an insurer to administer them; ERISA federal rules govern the appeal end to end, including external review.
- Fully insured plan
- A plan where an insurance company bears the financial risk and pays claims from premiums; the claim is also subject to state insurance law, including the state's external-review program.
- SPD
- Summary Plan Description — the plain-language summary of the plan given to participants; it is not the governing document when it conflicts with the full plan document.
- CARC / RARC
- Claim Adjustment Reason Code and Remittance Advice Remark Code — the official X12 code sets insurers use on an EOB to state why a claim was denied or reduced.
- External review
- An independent review of a denied claim by a reviewer outside the insurer, requested after the internal appeal is exhausted or deemed denied.
- Deemed denied
- A claim treated as denied because the plan missed its statutory decision deadline without a valid extension notice, letting the claimant proceed to external review.
