Anthem / Elevance Health Claim Denied: How to Fight Back

Anthem / Elevance Health Claim Denied: How to Fight Back

Anthem, now rebranded as Elevance Health, is one of the largest health insurers in the United States, serving approximately 45 million members through its Blue Cross Blue Shield affiliates across 14 states including California (Anthem Blue Cross), New York, Ohio, Georgia, Virginia, Missouri, Wisconsin, and others. If Anthem has denied your health insurance claim, federal law and state regulations give you enforceable rights to appeal — and a significant proportion of appealed claims are overturned.

About Anthem / Elevance Health

Anthem operates primarily as a Blue Cross Blue Shield licensee in most of its markets. Common plan names you may see include:

• Anthem Blue Cross (California)
• Anthem Blue Cross Blue Shield (multiple states)
• Empire Blue Cross Blue Shield (New York)
• Highmark Blue Cross Blue Shield (Pennsylvania, West Virginia, Delaware)

Anthem offers employer-sponsored (group) health plans, individual and family ACA marketplace plans, Medicare Advantage, Medicaid managed care, and federal employee benefit programs.

Common Anthem Denial Reasons

Medical necessity denials: Anthem's clinical reviewers use internal Clinical Criteria (published on anthem.com) to determine whether a service is medically necessary. Common examples:

• Inpatient hospitalization Anthem argues should be outpatient
• Procedures Anthem deems to have insufficient evidence
• Specialist consultations Anthem says are not required
• Imaging Anthem considers premature

Prior authorization denials: Anthem requires prior authorization for a wide range of services — surgical procedures, specialty drugs, medical equipment, and certain imaging. Denial of prior authorization flows through to claim denial.

Step therapy ("fail first") denials: Anthem frequently requires you to try cheaper, alternative treatments before approving your preferred treatment. If your doctor prescribed a specific medication or procedure, Anthem may deny it until you have "tried and failed" the alternatives.

Out-of-network denials: For HMO plans, out-of-network care is generally not covered. For PPO plans, out-of-network care is typically reimbursed at a lower rate but may be denied if the benefit is not included in your plan.

Coverage exclusion denials: Anthem plans exclude certain services — often cosmetic procedures, fertility treatment (unless mandated by state law), weight loss surgery (in some plans), and experimental therapies.

Mental health parity violations: Anthem has faced multiple regulatory actions and class-action lawsuits over mental health coverage. Under the Mental Health Parity and Addiction Equity Act (MHPAEA), Anthem cannot impose more restrictive limits on mental health benefits than on comparable medical/surgical benefits.

Your Legal Rights When Anthem Denies a Claim

Under the ACA and ERISA (for employer-sponsored plans), you have the right to:

1. A written denial notice with specific grounds and the plan provision or clinical criteria cited
2. Your complete claim file at no cost
3. A free internal appeal — Anthem must decide within 60 days (standard) or 72 hours (urgent)
4. A free external review by an Independent Review Organisation (IRO) after exhausting internal appeals — decisions are binding on Anthem
5. File a complaint with your state's Department of Insurance (Blue Cross Blue Shield plans are regulated at the state level)

Step-by-Step: How to Appeal an Anthem Denial

Step 1: Read Your Explanation of Benefits (EOB) Carefully

Anthem's denial notice (EOB) states the reason code for denial. Common Anthem reason codes include:

• "Service not medically necessary per clinical criteria"
• "Prior authorization not obtained"
• "Service not covered under your benefit plan"

Each denial reason requires a different appeal strategy.

Step 2: Request Your Complete Claim File and Clinical Criteria

Request Anthem's Clinical Criteria guidelines for the specific service denied. These are published on anthem.com but can also be requested specifically for your claim. Your appeal must directly rebut whatever clinical criteria Anthem used.

Step 3: Get a Detailed Physician Support Letter

Your appeal will be reviewed by Anthem's clinical staff. A compelling letter from your treating physician (or a specialist) should:

• State the specific diagnosis and why the requested service is medically necessary for your condition
• Address Anthem's clinical criteria directly (by name if possible)
• Cite peer-reviewed clinical guidelines from recognised professional bodies
• Explain why alternative treatments are not appropriate
• State the risks of not receiving the requested care

Step 4: Submit the Anthem Internal Appeal

Submit via:

• Online: Sydney Health app (Anthem's member app) or anthem.com member portal
• Mail: Use the address on your denial notice — Anthem has different appeal addresses by state
• Fax: See denial notice for fax number

What to include:

• A formal appeal letter addressing each denial reason
• Your physician's supporting letter
• Relevant medical records
• Any peer-reviewed research supporting your treatment
• Corrected billing information (if the denial was due to coding error)

Deadlines: Submit your internal appeal within 180 days of Anthem's denial notice (some states allow longer; check your denial notice).

Step 5: Request Expedited Appeal for Urgent Cases

If your medical condition is urgent and a 60-day wait would jeopardise your health, request an expedited internal appeal. Anthem must decide within 72 hours.

Step 6: Request External Review

After Anthem's final internal appeal decision (or if Anthem fails to decide within the required timeframe), request external review:

• Contact Anthem and request external review initiation
• Anthem will coordinate with an IRO approved by your state
• External review decisions are binding on Anthem
• Timeline: 45 days (standard) or 72 hours (expedited)
• Cost: Free for you

For self-insured ERISA plans, external review goes through a federal process — Anthem should provide instructions.

Step 7: File a State Insurance Complaint

File a complaint with your state's Department of Insurance simultaneously with or after your internal appeal. Blue Cross Blue Shield plans are regulated at the state level, giving state regulators direct oversight over Anthem in their state.

Find your state regulator at naic.org.

Anthem-Specific Appeal Timeline

Action	Deadline
Anthem internal appeal submission deadline	180 days from denial
Anthem standard appeal decision	60 days
Anthem expedited appeal decision	72 hours
External review request deadline	4 months post-final denial (varies by state)
External review standard decision	45 calendar days
External review expedited decision	72 hours

Anthem-Specific Tips

Step therapy overrides: Many states have passed step therapy override laws that require Anthem to grant exceptions when your physician certifies that the step therapy protocol is clinically inappropriate for you. If your state has a step therapy override law, include a specific physician certification in your appeal.

Emergency care: The No Surprises Act prohibits Anthem from requiring prior authorization for emergency services. If your denial involves emergency care from an out-of-network provider, cite the No Surprises Act in your appeal.

Mental health: If your denial involves mental health or substance use disorder, request that Anthem provide a comparative analysis showing that its criteria for your mental health benefit are no more restrictive than for comparable medical/surgical benefits (MHPAEA Non-Quantitative Treatment Limitation analysis). This is required by federal regulation.

Conclusion

Anthem (Elevance Health) denies millions of claims annually, but the ACA guarantees your right to appeal and — crucially — to an independent, binding external review. Don't accept Anthem's first denial as final. Build your appeal around Anthem's own clinical criteria, get your physician's detailed support, and escalate to external review if the internal appeal fails. Use ClaimBack at claimback.app to generate a professional, criteria-specific appeal letter designed to maximise your chances of overturning an Anthem denial.

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Related Reading:

• Kaiser Permanente Claim Denied: How to Appeal
• Blue Cross Blue Shield Claim Denied: How to Fight Back
• How to Write an Insurance Demand Letter
• How Long Does an Insurance Appeal Take?