How to Appeal an Insurance Company Decision — and Win

Insurance companies deny claims, reject prior authorizations, and make coverage decisions every day. What most people don't know is that a significant percentage of those decisions are overturned on appeal. If your insurance company said no, that may not be the final answer.

Why Appeals Work

Insurance companies process thousands of claims with automated systems. Denials are often issued based on incomplete information, coding errors, or a lack of supporting documentation — not because the care was genuinely not covered. When you appeal and provide the right documentation, the decision frequently changes.

Types of Appeals

• Internal appeal: Your first step. You formally request that the insurance company review the denial. Under the ACA, insurers must complete standard internal appeals within 30 days for pre-service requests and 60 days for post-service claims.
• Expedited appeal: Available when your health would be seriously jeopardized by waiting. Insurers must respond within 72 hours.
• External review: If your internal appeal is denied, you have the right to an independent external review by a third party not employed by the insurer. The insurer must abide by the external reviewer's decision.

What Makes a Strong Appeal

• A letter of medical necessity from your doctor explaining why the service was required
• Clinical guidelines or peer-reviewed literature supporting the treatment
• Your plan's Summary of Benefits and Coverage showing the service should be covered
• Copies of all previous communications with the carrier
• A clear written statement explaining why the denial was incorrect

Don't Miss the Deadline

Most plans require you to file an internal appeal within 180 days of receiving the denial notice. Missing this deadline can forfeit your right to appeal. Act promptly.

BenZen helps clients navigate coverage disputes across GA, FL, MD, VA, PA, and more. Reach out if you need guidance.