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Know Your Insurance Appeal Rights

Federal and state law guarantees your right to appeal every denied insurance claim. Your insurer must give you a fair review.

Understanding your rights is the first step to winning your appeal.

Analyse My Denial — Free →
Did you know? Fewer than 1 in 500 denied claimants exercise their right to external review — yet external reviewers overturn ~60% of denials.

6 Federal & State Protections That Apply to You

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ACA Appeal Rights

Affordable Care Act (2010) · Applies to: All ACA-compliant health plans

Every ACA plan must offer at least one level of internal appeal and an independent external review. Urgent claims must be reviewed within 72 hours.

Your rights include:
  • Right to an internal appeal within 180 days of denial
  • Right to an independent external review by a third-party reviewer
  • Expedited (72-hour) review for urgent medical situations
  • External review decisions are binding on the insurer
  • Right to receive your complete claim file
Insurance Appeal Guide →
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ERISA Protections

Employee Retirement Income Security Act (1974) · Applies to: Employer-sponsored health plans

ERISA requires employer-sponsored plans to follow specific claims procedures, provide written denial reasons, and allow full and fair review of denied claims.

Your rights include:
  • Written explanation of denial with specific reasons and plan provisions
  • At least 180 days to file an appeal
  • Right to submit additional evidence and have it considered
  • Decision within 30 days for pre-service claims, 60 days for post-service
  • Right to bring a lawsuit in federal court after exhausting appeals
ERISA Guide →
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Mental Health Parity

Mental Health Parity and Addiction Equity Act (MHPAEA) · Applies to: Most health plans covering mental health

Insurers cannot impose stricter limits on mental health and substance use treatment than they do on medical/surgical treatment.

Your rights include:
  • Equal visit limits, deductibles, and copays for mental health
  • Cannot require prior authorization for mental health if not required for comparable medical care
  • Right to request a parity compliance analysis from your insurer
  • Covers both in-network and out-of-network benefits equally
  • Strengthened by the 2024 final rule requiring outcomes-based analysis
Mental Health Parity Guide →
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No Surprises Act

No Surprises Act (2022) · Applies to: Emergency services, air ambulance, certain non-emergency care

Protects you from surprise medical bills when you receive emergency care or treatment from out-of-network providers at in-network facilities.

Your rights include:
  • Emergency services treated as in-network regardless of provider
  • Out-of-network providers at in-network facilities cannot balance-bill you
  • Independent dispute resolution for payment disagreements
  • Applies to both insured and self-pay patients (Good Faith Estimates)
  • Air ambulance services from out-of-network providers are covered
No Surprises Act Guide →
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External Review

Federal External Review Process · Applies to: All non-grandfathered health plans

After exhausting internal appeals, you can request an independent medical expert to review your denial. Their decision is binding on the insurer.

Your rights include:
  • Available after internal appeals are exhausted (or after 4 months of no response)
  • Reviewed by independent physicians with relevant expertise
  • Insurer must comply with the external reviewer's decision
  • Available for medical necessity, experimental treatment, and rescission denials
  • Typically free — costs are paid by the insurer
External Review Guide →
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State Consumer Protections

Varies by state · Applies to: State-regulated (fully insured) health plans

Most states provide additional protections beyond federal law, including faster review timelines, broader external review rights, and insurance department complaint processes.

Your rights include:
  • 35+ states have independent external review laws (many stronger than federal)
  • State insurance departments can investigate and fine insurers
  • Some states (CA, NY, IL) have dedicated health plan review programs
  • Prompt payment laws in most states (15-45 day deadlines)
  • Bad faith insurance laws allow lawsuits for unreasonable denials
Find Your State's Protections →

Appeal Timeline: What to Expect

Day 0
Receive denial letter
Your insurer sends an EOB or denial notice
1-7 days
Review and gather documents
Read denial, collect medical records, get doctor's letter
7-14 days
File internal appeal
Submit written appeal with all supporting documentation
30-60 days
Internal appeal decision
Insurer must respond within 30 days (pre-service) or 60 days (post-service)
60-90 days
File external review (if denied)
Request independent review within 4 months of final internal denial
90-135 days
External review decision
Independent reviewer issues binding decision within 45 days

Ready to exercise your rights?

ClaimBack uses AI and data from thousands of real denials to build your appeal letter — citing the specific laws and regulations that apply to your case.

Analyse My Denial — Free →View Appeal Checklist

Frequently Asked Questions

What is the difference between an internal appeal and an external review?

An internal appeal is reviewed by your insurance company — typically a different person or committee than the one who denied your claim originally. An external review is conducted by an independent third-party medical expert who has no affiliation with your insurer. External review decisions are legally binding on the insurer.

Do I have the right to appeal any insurance denial?

Yes. Under the ACA, all non-grandfathered health plans must provide at least one level of internal appeal and access to external review. ERISA plans must provide a "full and fair review." Some exclusions may apply to grandfathered plans, short-term plans, or health sharing ministries.

Can my insurer retaliate against me for filing an appeal?

No. It is illegal for an insurer to cancel your policy, raise your premiums, or otherwise retaliate against you for exercising your appeal rights. If you believe your insurer has retaliated, file a complaint with your state insurance department immediately.

What if my employer's HR department pressures me not to appeal?

ERISA protects your right to file claims and appeals without employer interference. Your employer cannot legally prevent you from appealing or retaliate against you for doing so. If you experience pressure, document it and consider contacting the Department of Labor.