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How to file a health insurance internal appeal

An internal appeal asks the plan to look again, with a different reviewer. Here is a practical order of work.

1. Confirm the deadline and address. Use the notice. For help, see the deadline guide.
2. Get the file and criteria. Ask for them, free of charge.
3. Answer the stated reason. If the denial says "not medically necessary," the appeal should address that exact sentence, ideally with a letter from the treating clinician that answers the plan's criteria point by point. State health departments' toolkits recommend citing the insurer's own medical policy and current clinical evidence where appropriate.
4. Write the letter. Use the letter builder. Include your name, policy ID, claim number, date of denial, the service, and what you ask them to do. The letter builder runs in your browser; nothing you type is sent anywhere.
5. Attach only what supports the appeal. The denial notice, clinician letter, relevant records, and any studies your clinician recommends. You do not need to share your entire medical history.
6. File with proof. Certified mail with return receipt, fax confirmation, or portal receipt. Keep copies.
7. Follow up. Plans must decide within set times (for group health: 30 days for pre-service and 60 days for post-service appeals in a one-level plan; 72 hours for urgent). Mark the date and call if you have heard nothing.

If your plan has two appeal levels

Each review is generally limited to half of the one-level time, and the plan must give a reasonable period, though not a full 180 days, to file the second. Read the SPD.

Missed something?

If the plan fails to follow required claim procedures, you may be able to go to external review right away. Ask the plan, your CAP or the Labor Department.