Appeal Your Insurance Claim Denial

Insurance companies must provide a written reason for every claim denial, and federal law under the ACA gives you the right to an internal appeal and an independent external review. Most denials cite 'medical necessity' — a determination that can be overturned with the right documentation.

Success rate: 55%  ·  Average recovered: $2,100  ·  Time limit: Internal appeal: within 180 days of denial notice. External review: 4 months after internal denial.

Winning Arguments

• Your treating physician documents medical necessity in writing
• The treatment is listed as covered in your plan documents
• Prior authorization was obtained or was not required
• The denial reason contradicts clinical guidelines (reference HEDIS standards)
• Emergency services cannot be denied for in-network cost-sharing reasons
• Mental health parity — if equivalent medical services are covered, mental health must be too

Laws That Protect You

• ACA Internal Appeal Rights (§2719)
• ACA External Review Rights
• ERISA (employer plan appeals)
• Mental Health Parity Act
• No Surprises Act

How to Dispute — Step by Step

1. Get the denial in writing and identify the specific denial reason
2. Request your complete claim file from the insurer
3. Have your doctor write a letter of medical necessity
4. Submit an internal appeal with supporting documentation
5. If internal appeal fails, request external independent review
6. File a complaint with your state insurance commissioner

What to Include in Your Dispute Letter

• Your full name, mailing address, and the account or bill number in question
• A clear statement that you are formally disputing the charge, and the specific reason why
• The law or billing right that supports your position (see the laws listed above)
• Copies — never originals — of receipts, statements, or correspondence as evidence
• A reasonable deadline for a written response, typically 30 days

A well-documented, written dispute that cites the right law puts the burden back on the biller to justify the charge. Keep a copy of everything you send, use certified mail when possible, and follow up in writing if you do not receive a timely response. ContestMyBill generates a letter that does all of this for you.

Frequently Asked Questions