How to Appeal a Denied Health Insurance Claim

You can often fight back, whether you're on Medicare, you're insured through an employer, or you buy your own health insurance

Gavel cut out of piece of paper on green background Illustration: Domenic Bahmann

Did you recently get a letter from your insurer denying coverage for a test, drug, or other healthcare treatment?

If so, you’re hardly alone, whether you get insurance through your employer, buy it on your own, or are on Medicare. One recent study, for example, found that 17 percent of claims from people insured through an Affordable Care Act marketplace plan were denied in 2018. Another study, of people covered through a large Medicare Advantage insurer, found that nearly a third had at least one claim denied over a one-year period. Those denials can leave you on the hook for big medical bills..

But you don’t have to take it lying down, says Caitlin Donovan, a health policy expert at the Patient Advocate Foundation. She notes that there are steps you can take to fight those denials, regardless of where you get your health insurance. If you sought preauthorization for a healthcare service and were denied, you can appeal that decision, too.

First off, mistakes can happen at multiple points in the claim filing or preauthorization process, so phone your insurer to make sure the decision was not made in error. If it was not, ask to speak to the reviewer behind the decision and request an explanation. Keep notes, because you’ll need this information in writing later, Donovan says.

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The second step is to file a formal appeal. Enlist your doctor’s help to write a letter that explains the necessity of the procedure, and include supporting documents, such as your medical records and studies about the treatment. State your case as to why you disagree with the decision to deny, Donovan says.

It could take 30 days or longer to get a response. For a test, drug, or procedure you haven’t yet received, you can ask for an expedited review.

If the insurer’s deter­mi­na­tion is to stand by the denial, both Medicare and private insurance must by law state the reason in writing and tell you how to appeal the decision with an independent third party.

If you’re dealing with Medicare, there are three additional actions you can take, eventually leading to a hearing before a judge. Consider getting legal help for any of them.

If you get your insurance through your employer, your company’s human resources department may be able to help. Ask the department to reconsider the denial, and say why you think it should.

See our special report, "How to Lower Your Medical Bills."

Editor’s Note: This article also appeared in the June 2022 issue of Consumer Reports magazine.

Head shot of CRO author Lisa Gill

Lisa L. Gill

As a dorky kid, I spent many a Saturday at the Bloomington, Ind., public library, scouring Consumer Reports back issues for great deals. Now, as a (much) bigger kid, that's still my job! Identifying products and services, especially in healthcare, that are safe, effective, and affordable—and highlighting those that aren't—is my top concern. Got a tip? Follow me on Twitter ( @Lisa_L_Gill)