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An insurance denial can feel like a final answer, but it may be the beginning of an appeal. Depending on your health plan and where you live, you may have the right to ask your insurer to reconsider a decision and, in many cases, have an independent reviewer look at it. The first step is understanding exactly why the request was denied and what your plan says about your appeal rights.
Ask your insurance company for the denial in writing. It should explain why the service was denied and provide information about your right to appeal and the applicable deadlines. Review the denial carefully and follow the instructions for filing an internal appeal.
Ask your child’s doctor or care team whether they can provide a letter of medical necessity explaining why the requested treatment or service is appropriate for your child. Supporting medical records, treatment history, clinical documentation, and relevant guidelines may also strengthen an appeal.
If your internal appeal is denied, you may have the right to request an external review by an independent reviewer. For plans subject to the federal external-review process, the request generally must be made within four months of receiving the final denial, and the external reviewer’s decision is binding on the insurance company. Standard external reviews are generally decided within 45 days.
The exact process, deadlines, and costs can vary depending on your plan and state, so check your final denial notice and plan documents for instructions.
When waiting for a standard review could seriously jeopardize your child’s health or ability to regain maximum function, you may be able to request an expedited external review. Under the federal external-review process, expedited reviews are decided as soon as possible and no later than 72 hours after the request is received. Your doctor or other medical professional may be able to help document the urgency.
You do not have to navigate an insurance appeal alone. Your state’s Consumer Assistance Program or Department of Insurance may be able to help with an appeal or external review. The Patient Advocate Foundation also provides free, one-on-one case management to eligible patients and families, including help with insurance denials and access to care.
Keep the denial letter, your insurance plan information, medical records, letters from your providers, appeal submissions, reference numbers, and notes from every conversation with your insurer. Write down the date, name or ID of the person you spoke with, and what was discussed. A clear record can make it much easier to keep track of deadlines and respond to the next step.