What are my options after a health insurance denial, and how do they compare?
Seven routes exist and five cost nothing: appeal it yourself with the plan's own file and criteria, ask the prescribing office for a peer-to-peer review and a medical-necessity letter, use your state's Consumer Assistance Program or insurance department (insured plans) or the U.S. Department of Labor (self-funded employer plans), get free SHIP counselling for Medicare, or legal aid for Medicaid. Paid help is a patient advocate (hourly or flat fee), an attorney (mostly after appeals are exhausted), or an appeal-preparation service such as Apellica ($0 upfront, 10% of what is recovered if it succeeds).
What to do, in order
- Step 1
Read the reason and the deadline on the letter
The reason decides which route fits. A prior-authorization or medical-necessity denial is usually best started with the prescribing office; a benefit exclusion or procedural denial is a document fight; a Medicare Advantage denial goes up a federal ladder.
- Step 2
Use the free routes first, in parallel
Ask the plan for the file and the criteria (free, on request). Ask the prescribing office for the peer-to-peer and the letter. Call the state program, EBSA or SHIP for your plan type. None of these prevent you from adding paid help later.
- Step 3
Decide who prepares the appeal
If you have the time and the record, do it yourself with the plan's criteria in hand. If you do not, choose between a fee-for-time advocate, a contingency service such as Apellica, or an attorney for a large or exhausted claim.
- Step 4
File early and keep proof
Whichever route you choose, the appeal must reach the plan before the date on the letter. Keep the fax confirmation, the certified-mail receipt or the portal record.
Side by side
Ways to fight a denial, compared. Free routes first. Deadlines are federal floors; the letter controls.
| Route | Cost | Best for | What it can and cannot do | How to start |
|---|---|---|---|---|
| Do it yourself | Free | Any denial where you have time and the record | You have the same rights as any representative: the file and the criteria free of charge, a decision in 30 or 60 days (72 hours urgent), and external review. It costs your time and the appeal has to be built to the plan's criteria. | Write to the address on the letter; use the free decoder, deadline calculator and letter generator on this site. |
| The prescribing or treating office | Free | Prior-authorization and medical-necessity denials | A peer-to-peer call with the plan's medical director and a letter of medical necessity written to the criteria. The office may not have time to run the full appeal. | Ask for the prior-authorization coordinator; give them the denial letter and the plan's criteria. |
| State Consumer Assistance Program or insurance department | Free | Insured employer, individual and Marketplace plans | Explains your rights, helps file, and takes complaints against state-regulated plans. Cannot act on self-funded employer plans, Medicare or TRICARE. | CMS keeps the directory of state programs; the insurance department's consumer line is on its website. |
| U.S. Department of Labor (EBSA) | Free | Self-funded employer plans (ERISA) | Benefits advisors explain ERISA rights and can contact the plan about procedural violations; EBSA does not decide the claim. | 1-866-444-3272 or askebsa.dol.gov. |
| SHIP counsellor (Medicare) or legal aid (Medicaid) | Free | Original Medicare, Medicare Advantage, Part D, Medicaid | Trained counsellors walk through the federal appeal ladder or the state fair-hearing process and help with the forms. | SHIP: 1-877-839-2675 or shiphelp.org. Medicaid: your state legal-aid office or ombudsman on the notice. |
| Independent patient advocate | Hourly or flat fee, paid whether or not the appeal succeeds | Complex cases with many moving parts, or a family that wants one person to coordinate | Case management, records gathering and appeal drafting; fees vary widely and are not contingent on the result. | Ask for the fee schedule in writing and whether they have handled your plan type. |
| Attorney | Hourly, or contingency for litigation | Large claims after internal appeals are exhausted, procedural violations, ERISA lawsuits | Can sue under ERISA or state law once appeals are exhausted; most will not take a routine internal appeal. Fee-shifting is possible in ERISA cases. | Search for ERISA or health-insurance litigation; ask about the exhaustion requirement and fees. |
| Apellica (appeal-preparation service) | $0 upfront; 10% of what is recovered, only if the appeal succeeds | Denials worth appealing where you want the appeal prepared and filed, with citations, and followed to external review | Prepares and files the internal appeal and the external-review request with the criteria demand, the record mapped to each criterion and the primary-source citations. Not a law firm; says so when a matter needs one. | Upload the letter for a free written assessment first; nothing is charged for a no. |
The deadline that applies
Employer and ACA plans: at least 180 days to file the internal appeal, about four months for external review after the final internal denial (29 CFR 2560.503-1; 45 CFR 147.136). Medicare Advantage and Part D: 65 days from the notice (42 CFR 422.582, 423.582). Original Medicare: 120 days. Medicaid managed care: 60 days (42 CFR 438.402). TRICARE: 90 days (32 CFR 199.10). The date on the letter controls.
Calculate your date →Documents to gather
- The denial letter or Explanation of Benefits, every page
- Your insurance card and the plan's summary of benefits or Summary Plan Description
- The clinical notes and test results that support the service
- A letter of medical necessity from the treating clinician, written to the plan's criteria
Go deeper
Related questions
Is a paid service worth it for a small claim?
Usually not. A prescription or visit worth a few hundred dollars is best appealed yourself or through the prescribing office. Contingency services and attorneys make sense when the amount, the complexity or the time cost is large.
Can I use more than one route at once?
Yes. A complaint to the state program or EBSA runs alongside the plan's own appeal, and the prescribing office's peer-to-peer can happen while the written appeal is being prepared. Only one written appeal per level should be filed, so coordinate who sends it.
How do I know whether Apellica will take my case?
Upload the letter. A reviewer reads it and answers in writing whether it can be appealed and how. If the answer is no, you are told what else is available and nothing is charged.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
Start a free denial review →