Health Insurance Claim Denied in the USA: Your ACA Appeal Rights

A health insurance claim denied USA doesn't mean game over. Federal law gives you multiple appeal paths, and insurers are strictly regulated. This guide shows you exactly how to fight back, step by step.

Whether you have employer coverage, an ACA plan, Medicare, or Medicaid, you have legal appeal rights. The key is knowing how to use them before the deadlines pass.

Here's your complete roadmap.

Your Federal Appeal Rights Under the ACA

The Affordable Care Act (ACA) created strict rules for claim appeals. Here's what you need to know:

The 180-Day Window: You have 180 days from the denial to file an appeal. This is your most important deadline.

Two-Tier System: Internal appeal (60 days), then external review if needed (72 hours to several months depending on urgency).

Urgent vs. Standard: Urgent denials (where waiting could harm your health) get faster reviews. Standard denials get more time but eventually resolve.

Independent Review: An external reviewer (not your insurer) can overturn the denial.

Expedited Option: If your condition is urgent, you can request expedited review—decisions within 72 hours, not weeks.

The system is built to protect you. Most denials are overturned on appeal because the insurer's initial decision was too hasty or wrong.

Step 1: Understand the Denial Letter

Your insurer must send you a written denial. This is the foundation of your appeal.

Look for:

• The specific medical reason (e.g., "not medically necessary")
• The policy provision cited
• What medical evidence they reviewed
• Why they determined the treatment wasn't covered
• Information about your appeal rights (this is required)

If the letter is vague, doesn't reference your medical file, or doesn't explain the reasoning, that's a red flag. Vague denials often don't survive appeal.

Read this letter multiple times. Underline the reasoning. This is what you'll address in your appeal.

Step 2: File Your Internal Appeal

This is your first formal step. The insurer must respond within 30 days for standard claims (urgent claims get 72 hours).

How to Appeal:

1. Contact your insurer's appeals department (number should be on the denial letter)
2. State: "I am requesting a formal internal appeal of the denial dated [date]"
3. Provide: claim number, date of denial, brief statement of why the denial is wrong
4. Send by phone, mail, or online portal—use whatever method gives you proof of submission
5. Follow up immediately with registered mail or email confirmation

What to Include:

• A clear statement that you're appealing
• Your policy number and claim number
• The date of the denial
• A brief explanation of why you believe the decision is wrong
• Any new medical evidence (doctor's letter, treatment guidelines, medical records)

Key Tactic: Request a Peer-to-Peer Review: Many denials cite "medical necessity." If this is your issue, request a peer-to-peer review—a conversation between your doctor and a doctor employed by the insurer. This is often enough to overturn the denial because your doctor can explain clinical reasoning directly.

In your appeal, write: "I request a peer-to-peer review between my treating physician and the insurer's medical reviewer."

What Happens:

• The insurer acknowledges receipt
• They review your file and any new evidence
• Within 30 days (or 72 hours for urgent), they issue a decision
• They must send this in writing with explanation of reasoning

If they deny the appeal, you can now move to external review.

Step 3: Request External Review (Independent Review)

If your internal appeal is denied (or after 30 days with no response), you can request an independent external review. This is powerful because it's not your insurer making the decision.

Who Handles External Review?

• State-appointed Independent Review Organizations (IROs) for health plans
• For ERISA plans (employer-sponsored), you may have different review rules
• The insurer must tell you which external reviewer to contact

How to Request:

1. Contact the independent review organization (IRO) your insurer specifies
2. Provide: your appeal denial letter, medical records, doctor's letter, your statement of why the denial is wrong
3. Request expedited review if urgent
4. Follow submission instructions (online, mail, phone)

Timeline:

• Expedited external review: 72 hours
• Standard external review: Up to 30 days
• Complex cases: Can extend to 72 days if additional evidence is needed

Power of External Review: External reviewers are independent. They don't work for your insurer. They're required to base their decision on medical evidence and guidelines—not profit. Many denials are overturned at this stage because the initial decision didn't hold up to independent scrutiny.

If the external reviewer determines the treatment should have been approved, the insurer must comply.

Step 4: State Insurance Commissioner Appeal

If you've exhausted the above and the denial still stands, you have one more option: the State Insurance Commissioner.

What the Commissioner Can Do:

• Investigate complaints about insurer misconduct
• Fine insurers for violations
• Force the insurer to reconsider the decision
• In some cases, award damages

How to File:

1. Go to your state's insurance department website
2. Find the complaint form (usually online)
3. File a complaint describing the denial and your appeals
4. The commissioner will investigate and contact the insurer
5. They'll issue findings

This is more administrative than court, but it can work. Commissioners take bad-faith denials seriously.

Step 5: ERISA Plan vs. ACA Plan—Do You Know Which You Have?

This matters because the appeal process is slightly different.

ACA Plans (purchased on healthcare.gov, healthcare.state.gov, or private exchanges):

• Governed by ACA rules
• State insurance commissioner oversees complaints
• Follow the process above

ERISA Plans (employer-sponsored):

• Governed by federal ERISA law
• Follow DOL (Department of Labor) rules
• Must have internal appeals, then external review available
• You can sue in federal court if you believe the denial violates ERISA

Medicare:

• Medicare has its own appeal process (different from above)
• Three levels: redetermination, reconsideration, appeal to Administrative Law Judge

Medicaid:

• State-based, but all states must offer appeals
• Process varies by state

Check your plan documents to know which category you're in. This determines your exact appeal process.

Common Denial Reasons—And How to Challenge Them

"Not Medically Necessary": The insurer says the treatment isn't clinically justified. Counter with: doctor's letter explaining why the treatment is necessary for your condition, clinical practice guidelines (NCCN, ASCO, ACCP) supporting the treatment, evidence that similar patients receive the same treatment, medical records showing your condition severity.

"Experimental or Investigational": The insurer says the treatment is unproven. Fight back with: published clinical trials showing the treatment's effectiveness, FDA approval status, clinical guidelines that include the treatment, evidence the treatment is widely used.

"Prior Authorization Not Obtained": The insurer denied because you didn't get approval first. This one's tough—but you can appeal based on: emergency care exception (if applicable), provider's failure to obtain authorization (not your fault), insurer's failure to communicate the requirement clearly.

"Out-of-Network": The provider wasn't in-network. Counter with: emergency care exception (if applicable), evidence the insurer didn't have in-network alternatives available, evidence the in-network provider was unavailable, continuity of care exception (if you were already being treated by this provider).

"No Coverage for This Diagnosis": The insurer claims your diagnosis isn't covered. Challenge with: policy language that contradicts this, medical evidence showing the diagnosis is real and documented, evidence that similar diagnoses are covered, professional guidelines recognizing the diagnosis.

Evidence That Wins Appeals

Your appeal's strength lies in medical evidence. Gather:

From Your Doctor:

• Detailed letter explaining why the treatment is medically necessary for your condition
• References to clinical guidelines supporting the treatment
• Explanation of why the insurer's denial doesn't align with medical standards
• Your medical history supporting urgency or severity

Clinical Guidelines:

• NCCN (National Comprehensive Cancer Network) guidelines
• ASCO (American Society of Clinical Oncology) guidelines
• ACCP (American College of Chest Physicians) guidelines
• Specialty society guidelines relevant to your condition

Medical Records:

• All test results and diagnoses
• Documentation of prior treatments
• Evidence of condition severity or progression
• Emergency room notes (if applicable)

Research:

• Published clinical trials supporting the treatment
• Evidence of FDA approval (if applicable)
• Peer-reviewed articles on the treatment's effectiveness

The Peer-to-Peer Review Tactic

This deserves its own emphasis because it's incredibly effective.

When you appeal a "not medically necessary" denial, request that your doctor speak directly with the insurer's reviewing physician. Often, once doctor-to-doctor conversation happens, the denial is immediately overturned.

In your appeal letter, write: "I request a peer-to-peer review between [your doctor's name] and the plan's medical director. Please arrange this within 5 business days."

Provide your doctor's phone number and encourage them to take the call. Many denials collapse at this stage because your doctor can explain clinical reasoning directly.

If You're Uninsured or Facing High Costs

If you don't have insurance or are facing huge bills while fighting the denial:

• Ask the healthcare provider about payment plans or financial assistance
• Ask about uninsured rates (often 50% less than insurance rates)
• Look into Medicaid emergency coverage if you qualify
• Ask about charity care programs

Don't let cost silence you. Appeal anyway.

Timeline Expectations

• Internal appeal decision: 30 days (expedited: 72 hours)
• External review decision: 30 days (expedited: 72 hours)
• State commissioner investigation: 30-60 days
• Total: 2-3 months in most cases

This is faster than you might think. Many people are surprised at how quickly external reviewers overturn denials.

Writing a Winning Appeal Letter

Your appeal must be clear, evidence-backed, and professional. No emotion—just facts.

Start with the denial reason. Then show (with evidence) why it's wrong. Reference medical guidelines. Request peer-to-peer review. Ask for the outcome.

ClaimBack can analyse your case and write your appeal letter in minutes — Start Free →

We'll analyze your denial, your medical records, your policy, and federal ACA requirements, then generate a professional appeal letter. You review it, send it, and let the insurer see how strong your case is.

Pre-Appeal Checklist

• I have my denial letter
• I know whether I have an ACA, ERISA, Medicare, or Medicaid plan
• I have gathered all medical records and test results
• I have a letter from my doctor supporting medical necessity
• I have researched clinical guidelines supporting the treatment
• I have proof of the 180-day appeal deadline (from denial date)
• I know the insurer's appeals department contact information
• I understand what external review means
• I have an organized evidence pack ready to submit

You have strong legal protections. Use them.

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Disclaimer: ClaimBack provides AI-generated appeal assistance for informational purposes only. ClaimBack is not a law firm and does not provide legal advice. Always review your appeal letter before sending and consider professional advice for complex or high-value claims. Regulatory processes vary — always verify current procedures with your insurer or regulator.

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Ready to fight your denial? ClaimBack analyses your case and writes a professional appeal letter in minutes — Start Free →