You have rights. Here's exactly how to fight back — by state, by insurer, and by denial reason.
Takes 3 minutes · No login required · Cites your state's regulations
Federal law gives you multiple layers of appeal rights. Understanding the process is your first weapon.
All ACA-compliant plans must offer an internal appeals process. You have 180 days from the denial notice to file. For urgent or concurrent care situations, expedited appeals must be decided within 72 hours. Your insurer must provide a written explanation of the denial and cite specific plan provisions or clinical criteria used.
After an internal denial, request an Independent External Review (IRO) under ACA §2719. An accredited, independent organization reviews your case. The IRO's decision is binding on your insurer — they must comply regardless. Approximately 72% of external reviews favor the patient, making this one of the most powerful tools available.
Each state has its own Insurance Department that regulates fully-insured plans (individual, small-group, and some large-group plans). ERISA self-funded employer plans are regulated federally by the Department of Labor's Employee Benefits Security Administration (EBSA). Filing a complaint with your state regulator can trigger an independent investigation.
The No Surprises Act (effective January 2022) limits balance billing from out-of-network providers in emergencies and requires cost-sharing protections for surprise bills. In emergencies, you can only be charged your in-network cost-sharing amount regardless of whether the provider is in-network. This law covers most private health plans.
Knowing why your claim was denied determines your appeal strategy. Each reason has a proven counter-argument.
The insurer determined that the treatment or procedure does not meet their criteria for medical necessity. This is the most common denial reason.
The service required advance approval from the insurer before it was provided, and that approval was not obtained.
The provider who delivered care was not in the insurer's contracted network, resulting in higher cost-sharing or full denial.
The insurer claims the condition existed before your coverage began and is therefore excluded from coverage.
The claim was denied because required supporting documents — such as referrals, medical records, or itemized bills — were not included.
The insurer claims the specific treatment, service, or condition is explicitly excluded under your policy terms.
These procedures face the highest denial rates. Each has a dedicated appeal guide with insurer-specific tactics.
Each insurer has different appeal processes, timelines, and pressure points. Get the tactics that work for your specific insurer.
Fully-insured plans are regulated by your state, and each state has its own deadlines, regulators, and consumer protections. Find yours.
Three tools that give you an immediate advantage in the appeals process.
Know exactly when you need to file your appeal. Missing a deadline forfeits your rights.
See how often your procedure gets denied by your specific insurer — and what that means for your case.
Free professional appeal letter in 3 minutes. Cites ACA regulations, clinical guidelines, and your state's laws.
Official federal and state resources to file complaints and trigger external review at no cost.
File appeals and complaints for ACA Marketplace plans, Medicare Advantage, and Medicaid.
healthcare.gov/appeal-a-marketplace-decision ↗For employer-sponsored self-funded plans governed by ERISA. EBSA can investigate violations and compel compliance.
dol.gov/agencies/ebsa ↗The National Association of Insurance Commissioners maintains a directory of all state insurance departments.
naic.org ↗Use your state's Insurance Department to file complaints against fully-insured plans and trigger independent external review. Filing a complaint is free and can compel insurer action within days.
For ACA-compliant plans, you have 180 days from receiving the denial notice to file an internal appeal. For urgent or concurrent care denials, you can request an expedited internal appeal that must be decided within 72 hours. After an internal denial, you have 4 months (120 days) to request an Independent External Review (IRO) under federal ACA rules. ERISA employer plans follow similar timelines but are governed by Department of Labor regulations.
An Independent External Review (also called an Independent Review Organization or IRO review) is a process under ACA §2719 where an accredited, independent organization reviews your denied claim after the insurer has upheld its denial internally. The IRO's decision is legally binding on your insurer — they must comply even if they disagree. Approximately 72% of external reviews favor the patient, making this one of the most powerful tools available to denied claimants. The process is free for consumers.
Yes. The No Surprises Act, effective January 2022, protects you from surprise medical bills in two key scenarios: emergency care at out-of-network facilities, and non-emergency care from out-of-network providers at in-network facilities (unless you gave prior informed consent). In these situations, you can only be charged your in-network cost-sharing amount. If you received a surprise bill, you can dispute it through your insurer's internal process or file a complaint with CMS.
Yes. Most employer-sponsored health plans are governed by ERISA (Employee Retirement Income Security Act), which gives you rights to appeal denied claims. Under ERISA, you must exhaust the plan's internal appeal process before pursuing legal action. After a final internal denial, you can request an Independent External Review if the plan is ACA-compliant, or file a complaint with the Department of Labor's Employee Benefits Security Administration (EBSA). ERISA plans must provide a full and fair review of your claim.
You have 30–180 days to appeal depending on your plan type. ClaimBack generates a free, regulation-citing appeal letter in minutes.
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