Fight Back Against Unfair Denials

Don't Accept "No" for an Answer

Insurers denied 19% of in-network marketplace claims in 2024, and fewer than 1% were ever appealed.
When people do appeal, roughly 1 in 3 appeals succeeds.

1 in 3
Appeals Succeed
<1%
Of Denials Ever Appealed
1 in 5
Claims Denied
180
Days to Appeal

Sources: KFF analysis of 2024 HealthCare.gov marketplace claims data (denial, appeal, and overturn rates). Figures describe marketplace plans; individual results vary and no outcome is guaranteed.

AI-Powered Appeal Letter Generator

Step-by-step wizard
Enter denial details or upload your letter
15 denial reason codes
Pre-built strategies for each denial type
Legal citations included
ERISA, ACA, No Surprises Act, state laws
4 appeal levels
Internal, 2nd internal, external, regulatory
Deadline calculator
Never miss your appeal window
Download as Word/PDF
Edit and customize your letter
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The Appeals Process Explained

1

First Internal Appeal

180 days (ERISA) / varies by plan

Submit written appeal to your insurance company with supporting documentation.

Include letter of medical necessity
Cite clinical guidelines
Keep copies of everything
2

Second Internal Appeal

60 days from first denial

If first appeal is denied, file a second-level internal appeal with additional evidence.

Address specific reasons for first denial
Add new evidence if available
Request peer-to-peer review
3

External Review

4 months (120 days) from final internal denial

Request review by an Independent Review Organization (IRO) not affiliated with your insurer.

IROs overturn denials more often than internal reviews
Request reviewer with relevant specialty
This decision is binding
4

Regulatory Complaint

Varies by state

File a complaint with your state insurance commissioner or Department of Labor (ERISA plans).

Document pattern of bad faith if applicable
Insurance commissioners can investigate
May lead to systemic changes
Example Scenarios

How Appeals Can Win

Example scenarios illustrating potential outcomes, not verified individual testimonials.

Example Scenario — Texas
MRI denial
$2,800
MRI denied as not medically necessary
Coverage approved on first appeal
Tip: "A detailed letter of medical necessity from the treating physician can make the difference."
Example Scenario — California
Surgery denial
$45,000
Surgery denied as experimental
Approved after external review
Tip: "Citing other insurers that cover the same procedure can undercut an "experimental" denial."
Example Scenario — New York
ER visit denial
$8,500
ER visit denied as non-emergency
Covered under prudent layperson standard
Tip: "The No Surprises Act can protect patients from balance billing on emergency care."

Know Your Rights

Federal and state laws protect your right to appeal

ERISA (Employer Plans)

If your insurance comes through your employer, ERISA Section 503 guarantees your right to:
  • - Full and fair review of denied claims
  • - Written explanation of denial reasons
  • - Access to documents used in the decision
  • - At least 180 days to file an appeal, prior authorization denials included

ACA (Marketplace Plans)

The Affordable Care Act Section 2719 provides:
  • - Right to internal and external appeals
  • - External review by independent organization
  • - Expedited review for urgent situations
  • - External review decision is binding

No Surprises Act

Since January 2022, you're protected from:
  • - Surprise bills from out-of-network emergency care
  • - Balance billing at in-network facilities
  • - Surprise air ambulance bills
  • - Right to dispute through independent process

State Protections

Many states have additional protections:
  • - Surprise billing laws (before federal law)
  • - Network adequacy requirements
  • - Prompt pay statutes
  • - Mental health parity enforcement

Ready to Fight Your Denial?

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Cancel anytime. Individual results vary — appeal outcomes depend on your plan, claim, and documentation.