Is this appeal kit free?

Yes. The kit unlocks immediately after you enter your contact details. Unlocking it means a licensed insurance agent may follow up — that is what the consent covers. There is no cost, and no purchase is required.

How long do I have to appeal a denial?

For a non-grandfathered plan, you have 180 days from the denial notice to file an internal appeal. If that appeal upholds the denial, you generally have four months from the final internal-denial notice to request an independent external review. These are the federal timeframes; your own denial letter and plan documents state the exact process and address, and a few state processes differ, so always follow the instructions in your letter.

Is the external reviewer really independent of my insurer?

Yes. The external review is conducted by an independent review organization that the plan does not control, and its decision is binding — if it overturns the denial, the plan must provide the coverage or pay the claim. Some states run their own external review process meeting the federal standard; otherwise the federal process applies. This kit is general information about those federal rights, not legal or medical advice.

Free guide · plan year 2026

Denied claim appeal kit

Updated for plan year 2026

A denial letter is not the end of the conversation. Under federal law, a plan that denies a claim or refuses to cover a service has to give you a way to challenge that decision — first inside the company, then in front of an independent reviewer the company does not control. This kit explains the two stages, marks the deadlines, gives you a document checklist, and provides a fill-in appeal letter you can copy and send.

What’s inside

What a denial actually means — and why many denials are administrative (a coding error, a missing referral, a skipped prior authorization) rather than a judgment on the medicine
The two stages and their deadlines: the internal appeal (file within 180 days) and the independent external review (request within four months of the final internal denial)
How fast the plan must decide — 30 days for care not yet received, 60 days for care already received, 72 hours when the situation is urgent
A document checklist to gather before you write, from the denial letter and claim number to a letter of medical necessity
A fill-in appeal letter template — copy it, fill the blanks, keep a copy, and send it so delivery is tracked

Who it’s for: For anyone whose health plan has denied a claim or refused to cover a service and wants to appeal — and for the family member helping them do it.

How it works

A denial is the plan's position, in writing, that it will not pay for something — a service, a medication, a claim already incurred. The letter must tell you why and how to appeal. Read the reason closely: many denials are administrative — a coding error, a missing referral, an out-of-network technicality, a prior-authorization step skipped — and are resolved by supplying what was missing, not by arguing the medicine.

Federal law gives non-grandfathered plans — those created or substantially changed after March 2010, which includes every marketplace plan — a two-stage appeal. The first stage is the internal appeal: you file within 180 days of the denial notice, and the plan must decide within 30 days for care you have not yet received, 60 days for care already received, and 72 hours for an urgent situation.

If the internal appeal upholds the denial, the second stage is an external review by an independent review organization the plan does not control. You request it within four months of the final internal denial. The reviewer decides within 45 days for a standard review, or within 72 hours when expedited. The external reviewer's decision is binding: if it overturns the denial, the plan must provide the coverage or pay the claim. In an urgent health situation, you can request the external review at the same time as the internal appeal rather than waiting.

Some states run their own external review process that meets the federal standard; the denial letter or your plan documents tell you which process applies and where to send the request. Before you write, gather the denial letter and claim number, your plan documents, your provider's records and a letter of medical necessity if the denial questions whether the care was needed, any prior-authorization numbers, and a dated log of every call. A short, factual letter is the most effective kind.

All figures you compute using this appeal kit are estimates for comparison, not quotes. Actual premiums, subsidies, and eligibility are determined at enrollment. The Insurance Guide is independent — not HealthCare.gov, a state marketplace, an insurer, or a government agency.

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Frequently asked questions

Is this appeal kit free?: Yes. The kit unlocks immediately after you enter your contact details. Unlocking it means a licensed insurance agent may follow up — that is what the consent covers. There is no cost, and no purchase is required.
How long do I have to appeal a denial?: For a non-grandfathered plan, you have 180 days from the denial notice to file an internal appeal. If that appeal upholds the denial, you generally have four months from the final internal-denial notice to request an independent external review. These are the federal timeframes; your own denial letter and plan documents state the exact process and address, and a few state processes differ, so always follow the instructions in your letter.
Is the external reviewer really independent of my insurer?: Yes. The external review is conducted by an independent review organization that the plan does not control, and its decision is binding — if it overturns the denial, the plan must provide the coverage or pay the claim. Some states run their own external review process meeting the federal standard; otherwise the federal process applies. This kit is general information about those federal rights, not legal or medical advice.