When your health insurance claim is denied, you have the legal right to request an internal review of that decision. This process — called an internal appeal — is governed by federal law and gives you the opportunity to present new information and arguments before an independent reviewer within the insurance company. Understanding the process is the first step to using it effectively.
Your Legal Right to Appeal
Under the Affordable Care Act §2719 (45 CFR §147.136) and ERISA §503 (29 CFR §2560.503-1), all non-grandfathered health plans must have a meaningful internal appeals process. This right cannot be waived or limited by your plan. Key guaranteed rights include:
- The right to appeal any adverse benefit determination
- The right to submit evidence and testimony
- The right to receive all information used in the denial decision, free of charge
- The right to have your case decided by someone who was not involved in the original denial
- For medical necessity denials: review by a clinician with appropriate specialty expertise
- For urgent care: the right to an expedited process with a 72-hour decision deadline
Step-by-Step: Filing Your Internal Appeal
Your appeal clock starts when you receive the denial notice. Most plans allow 180 days to file. Use our Deadline Calculator for your exact deadline. Don't wait — the sooner you file, the sooner you'll receive an answer.
Within 5-7 days of the denial, request a copy of your complete claim file from the insurer. Under 29 CFR §2560.503-1(h)(2)(iii), you're entitled to this for free. The file contains the criteria used, the reviewer's notes, and the clinical guidelines applied — all of which you'll use in your appeal.
Read your denial letter carefully and identify the exact reason(s) for denial. Use our EOB Decoder for denial codes and our Denial Checklist to check if the denial is procedurally defective.
Build your evidence package: Letter of Medical Necessity from your treating physician, relevant medical records, clinical guidelines supporting your treatment, peer-reviewed studies, and documentation of prior treatments tried. The more comprehensive your package, the better your chances.
Your appeal letter should: identify the specific denial and the reason you're challenging it; present your clinical evidence; cite applicable federal regulations; request specific relief (reversal and approval); and note your right to external review. Use our Letter Generator for a complete, regulatory-compliant template.
Submit via certified mail with return receipt requested (keeps a timestamped record) OR through the insurer's online portal (get a confirmation number). Keep copies of everything. Note the submission date and the expected response deadline.
Your insurer must respond within required timeframes. If they don't respond on time, that constitutes a "deemed denial" you can escalate. Keep a log of all contacts with the insurer.
Response Deadlines for Insurers
Under 45 CFR §147.136 and 29 CFR §2560.503-1(f)(3), insurers must respond to internal appeals within:
- Pre-service (non-urgent): 30 days (one 15-day extension for information gathering)
- Pre-service (urgent/expedited): 72 hours (one 48-hour extension)
- Post-service (retrospective claims): 60 days (one 60-day extension for information gathering)
- Concurrent review (ongoing treatment): 24 hours for urgent concurrent reviews
What the Insurer Must Consider
The ACA requires that internal appeals be conducted as a "full and fair review." This means the reviewer:
- Must consider all information you submitted, including new information not available at the time of the original denial
- Cannot simply rubber-stamp the original denial — the review must be truly independent
- For medical judgments: must consult with a healthcare professional who has appropriate training and experience in the relevant clinical area
- Must not be the same individual who made the initial denial determination, or a subordinate of that individual
If Your Internal Appeal Is Denied
An internal appeal denial is not the end of the road. You have the right to:
- File for external review — an independent review by an organization completely outside your insurer. Use our External Review Checker.
- File a complaint with your State Insurance Commissioner (for state-regulated plans) or the U.S. Department of Labor (for ERISA employer plans)
- Pursue legal action — ERISA provides a private right of action; state law provides additional remedies for state-regulated plans
Pro Tip: Don't Submit a Bare-Minimum Appeal
In ERISA litigation, courts generally limit you to the evidence that was in the administrative record during the appeal. This means your internal appeal is your best opportunity to get everything into the record. Submit all clinical evidence, studies, and arguments you have — don't save anything for "later." A thorough appeal also makes external review and litigation more effective.