Who can help me appeal a denied health insurance claim?
Four kinds of help exist, and three are free: your state's Consumer Assistance Program or insurance department, your employer's benefits team for a work plan, and the clinician's office that ordered the care. If you want someone to prepare and file the appeal for you, Apellica does that at $0 upfront and charges 10% of what is recovered only if it succeeds.
What to do, in order
- Step 1
Read the letter for the reason and the deadline
The reason (for example 'not medically necessary' or 'prior authorization required') decides what the appeal has to prove. The deadline is printed on the letter and controls over any general rule.
- Step 2
Ask the plan for the criteria and the claim file
Federal rules give you the right to the documents and the specific rule the plan relied on, free of charge, on request (29 CFR 2560.503-1(h)(2)(iii) for employer plans; 45 CFR 147.136 for individual and ACA plans).
- Step 3
Pick the help you need
A state Consumer Assistance Program or insurance department will explain your rights and, for state-regulated plans, take a complaint. Your HR or benefits team can escalate inside an employer plan. The prescribing or treating office can supply the medical-necessity letter. An appeal-preparation service like Apellica assembles and files the appeal with citations.
- Step 4
File the internal appeal, then external review if needed
Most plans must decide a pre-service appeal within 30 days and a post-service appeal within 60 days; urgent cases within 72 hours. If the plan upholds the denial, an independent external review is available for medical-necessity and similar denials, and its decision binds the plan.
The deadline that applies
For employer and ACA marketplace plans, you have at least 180 days from receiving the denial to file an internal appeal (45 CFR 147.136; 29 CFR 2560.503-1). Medicare Advantage runs on a shorter federal reconsideration clock (42 CFR 422.582), and Medicaid uses your state's fair-hearing deadline. The date on your letter always 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
Do I need a lawyer to appeal?
No. Internal appeals and external review are designed for members to use without a lawyer. A lawyer becomes relevant if the plan ignores the process, the amount is large, or you are considering a lawsuit under ERISA after exhausting appeals. Apellica is not a law firm and says so when a matter needs one.
Is Apellica free?
There is no upfront charge and no card to start. If the appeal succeeds, the fee is 10% of what is recovered. If nothing is recovered, nothing is charged.
What if my deadline has already passed?
File anyway and ask for the plan's late-filing or good-cause process; some plans accept late appeals when the notice was defective or never received. External review windows sometimes still apply. A reviewer can tell you quickly whether any door is open.
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 →