This content is for general informational purposes and does not constitute medical, legal, or financial advice. Healthcare rules and costs change annually. Last reviewed: January 1, 2025. Always verify current details with your insurer, employer, or a licensed healthcare navigator.
Appeal (Claim Denial)
A formal process to challenge your insurer's decision to deny a claim or service.
Full Definition
An appeal is a formal request to have your insurance company review and reconsider a decision to deny a claim, service, or prior authorization. Most plans must allow at least one internal appeal. After exhausting internal appeals, you may have the right to an independent external review by a third-party organization. The ACA established minimum standards for the appeals process. Always appeal denials — a significant percentage are overturned. You typically have 180 days from the denial notice to file an appeal.
Real-World Example
Your insurer denies coverage for a medication your doctor prescribed, citing 'not medically necessary.' You file a formal appeal with your doctor's supporting documentation. The insurer's medical team reviews and overturns the denial within 30 days, approving the medication.
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