Appeals Roadmap

This guide walks through what to do after a health insurance claim is denied—from reading the notice and gathering records to filing an internal appeal and requesting external review if needed. Every plan is different, and timeline and requirements vary by state, but the high-level path to resolution is usually the same.

1. Read the denial letter carefully

Start by reviewing the denial letter or Explanation of Benefits (EOB). Look for the reason the claim was denied, the date of the denial, the claim number, the service or treatment involved, and the deadline to appeal. The letter should also explain how to file an appeal and where to send it.

Do not assume the insurance company is correct. Denials can happen because of simple mistakes, such as an incorrect billing code, missing medical records, or a provider submitting the wrong documentation. If the reason code or wording is unclear, use the Denial Decoder to understand what the denial usually means and what to do next.

2. Call the insurance company and ask for details

Call the number on your insurance card or denial letter. Ask the representative to explain the denial in plain language. Take notes during the call, including the date, time, person's name, reference number, and what they told you.

Useful questions include:

• "What specific rule or policy was used to deny this claim?"
• "Was this denied for medical necessity, coverage, coding, prior authorization, or another reason?"
• "What documents would help support an appeal?"
• "Is this something the provider can correct and resubmit?"
• "What is my appeal deadline?"
• "Can my doctor request a peer-to-peer review with your medical reviewer?"

If the denial mentions authorization, see Prior Authorizations and the Denial Decoder for how those denials usually work.

3. Contact your doctor or provider's billing office

Your provider may be able to help. If the denial was caused by a coding issue or missing information, the provider may be able to submit a corrected claim. If the denial involves medical necessity, ask your doctor for a letter explaining why the treatment, medication, test, or procedure was medically necessary.

A strong appeal often includes medical records, test results, treatment history, clinical notes, and a letter from your doctor connecting the service to your diagnosis and care plan. See Building a Strong Appeal Packet for what to include.

4. Ask whether a peer-to-peer review is available

A peer-to-peer review (sometimes called a P2P) is a phone conversation between your treating clinician—usually your doctor—and a medical reviewer at the insurance company. The patient is typically not on the call, but you can ask your care team to request one and help them prepare.

Peer-to-peer is most often available when the dispute is about clinical judgment, not billing paperwork. Common situations include:

• A prior authorizationwas denied before treatment, and the plan will let the prescriber discuss medical necessity with the insurer's reviewer
• A denial for medical necessity, experimental or investigational treatment, or a specialty drug during an appeal
• A step therapy or formulary exception where the doctor needs to explain why a preferred option will not work for this patient
• An inpatient admission, surgery, imaging, or infusion the plan wants to limit or delay based on its clinical criteria

Peer-to-peer is usually not the right tool for pure coding errors, missing claims information, or out-of-network billing disputes—those are often fixed with corrected claims or a written appeal instead.

Ask the insurer whether P2P is offered for this denial, who must initiate it (often the prescribing or treating physician), and any deadline to schedule the call. Some state laws require plans to offer peer-to-peer in certain prior authorization cases—check your state playbook if applicable. See Prior authorizations for the general workflow.

5. Gather your documents

Create a simple appeal file. Include your denial letter, insurance card, claim number, medical bills, EOB, medical records, doctor's letter, prior authorization documents, referral records, and notes from phone calls.

Keep the originals for yourself and send copies unless the plan specifically requires otherwise. If you mail the appeal, use a trackable method so you can prove when it was sent.

6. Write a clear appeal letter

Your appeal letter does not need to be long. It should clearly state who you are, what claim you are appealing, why you disagree with the denial, and what you want the insurance company to do.

Include:

• Your name, insurance ID number, and claim number
• The date of service and provider name
• The denied treatment, test, medication, or bill
• The reason given for denial
• A short explanation of why the denial should be reversed
• A list of attached documents
• A request for written confirmation and approval

Be direct and specific. If your plan documents say the service is covered, cite the relevant section. If the insurer says the service was not medically necessary, include your doctor's explanation and supporting records. The Appeals Generator and appeal templates can help you draft language to review with your clinician.

7. File the internal appeal before the deadline

The first appeal is usually called an internal appeal because the insurance company reviews its own decision. Follow the instructions in the denial letter exactly. Submit all required forms and supporting documents before the deadline.

Deadlines, forms, and where to send appeals vary by plan type and state. Use the State insurers & legislationsection on the Insurance topic page to open your state playbook—then follow that state's internal appeals guides and carrier links (for example, Indiana prior auth & internal appeals). See also how appeals change by plan type.

If a peer-to-peer does not resolve the issue, or the plan does not offer one, continue with your written appeal and supporting records. If your situation is urgent and waiting could seriously harm your health, ask for an expedited appeal(sometimes called urgent review). Say clearly why delay is dangerous, cite supporting records, and ask for the insurer's expedited deadline in writing. The same request may apply to external review if you reach that step.

8. Ask for an external review if the denial is upheld

If the insurance company denies your internal appeal, you may have the right to request an external review. This means an independent reviewer outside the insurance company looks at the case. External review is especially important when the denial involves medical judgment, medical necessity, or a treatment the plan calls experimental or investigational.

If the external reviewer decides in your favor, the insurance company generally must follow that decision. For state programs and filing contacts, start from State insurers & legislation on the Insurance topic page (state pages also list external appeal resources under External appeals where available).

9. Know when to get extra help

You do not have to handle the process alone. Your doctor's office, hospital billing department, employer benefits department, state insurance department, consumer assistance program, or patient advocate may be able to help.

When a denial involves a self-funded employer plan, federal rules may apply instead of state insurance department review—see Self-funded ERISA plans. For when to contact regulators, see Complaints to regulators.

If the denial involves a large bill, ongoing treatment, disability benefits, or a complicated legal issue, consider speaking with an attorney or professional patient advocate.

10. Stay organized and persistent

Appeals are won by making the reviewer's job easy. Submit a clear explanation, strong medical support, and the documents that directly address the reason for denial. Track every deadline, keep copies of everything, and ask for written confirmation whenever possible.

A denial is frustrating, but it is often just the beginning of the process. By understanding the reason for the denial, gathering the right evidence, and filing a timely appeal, you give yourself the best chance of getting the decision reversed.