Alyssa Lane
If your health insurance company refuses to pay for your medication, you have the right to appeal their decision. The appeals process can be time-consuming and daunting, but it can be made easier by understanding the reason for the denial, which should be outlined in a document called an Explanation of Benefits (EOB) from your insurer. This document should also explain how to appeal the decision and where to get help. There are multiple levels of appeal, with the first step being an internal review, where a full and fair reconsideration of the decision is requested from the insurance company. If this is denied, additional levels will be outlined in the denial documents.
| Characteristics | Values |
|---|---|
| Can I appeal? | Yes, you have the right to appeal. |
| What if I need the medication urgently? | You can request an expedited appeal which requires the insurance company to make a decision within 72 hours. |
| What is the process? | There are two ways to appeal a health plan decision: Internal appeal and External review. |
| What is an Internal appeal? | You may ask your insurance company to conduct a full and fair review of its decision. |
| What is an External review? | You have the right to take your appeal to an independent third party for review. |
| What if my insurance is provided by my employer? | Contact your human resources department for information about how best to proceed. |
| What if I have Medicare coverage? | Check your Medicare & You handbook for the specific process. |
| What are the levels of appeal? | First-level appeal, Level 1 appeal (redeterminations), Level 2 appeal, Level 3 appeal |
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What You'll Learn
Appealing to an external review organisation
If your health insurance company refuses to pay a claim, you have the right to appeal the company's decision and have it reviewed by a third party. This is called an external review. An external review means that the insurance company no longer gets the final say over whether to pay a claim.
Before you request an external review, you must go through an internal appeal with your health plan. You will need to reach out to your insurer for information. Your health plan will then issue a 'Final Adverse Benefit Determination Letter'. If they deny your request again, you can start an Independent External Review. You must request a review within four months from the date of the 'Final Adverse Benefit Determination Letter'.
You can appoint a representative (like your doctor or another medical professional) who knows about your medical condition to file an external review on your behalf. An authorized representative form is available on the externalappeal.cms.gov website. If your health insurance company is using the HHS-Administered Federal External Review Process, there’s no charge. If your issuer has contracted with an independent review organization, or is using a state external review process, you may be charged a fee not exceeding $25 per external review.
If you submit an expedited external review request, the review organization will issue a decision within 72 hours of its assignment. Your health plan must act on the review organization's decision within 24 hours. An independent review organization will have doctors and health professionals conduct the review. The group selected for your case will specialize in the same area of healthcare as your request.
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Understanding why your claim was denied
There are several reasons why your health insurance claim may have been denied. One common reason is that the service or medication was not considered medically necessary by the insurance company. In this case, your insurance carrier may require extra documentation from your healthcare provider to confirm that the test, procedure, or medication was medically necessary. Another reason for denial could be administrative, for example, if your healthcare provider used the wrong billing codes or filed the bill after the due date.
In some cases, your request for coverage may be sent to a third-party independent administrator to determine if it should be honored. Pharmacy benefit managers (PBMs) are one such third-party administrator that manages prescription drug benefits on behalf of health insurance plans. If your medication is not on their formulary, or list of preferred drugs, they are required to provide an equivalent option. If the equivalent option is unacceptable, your healthcare provider may need to appeal on your behalf.
If you are unsure why your claim was denied, you can contact your insurance company to request more information. You may also wish to consult your healthcare provider to discuss the denial and determine your next steps. Understanding the specific reason for the denial will help you decide how to proceed and whether to initiate the appeals process.
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Requesting an expedited appeal
If your health insurance company refuses to pay a claim, you have the right to appeal the decision and request an expedited appeal. An expedited appeal is a fast-tracked process where the insurance company must speed up their review of their initial decision. You can request an expedited appeal if you or your doctor believe that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.
To request an expedited appeal, you or your prescriber must typically make a request in writing. Contact your insurance plan to get a coverage determination and follow the directions in the plan's initial denial notice and plan materials to start your appeal. You will need to provide your name, address, phone number, and insurance number. If you have appointed a representative, you will also need to provide their name, address, and phone number, as well as any other relevant information, such as a prescriber supporting statement.
It is important to note that you usually have a limited time frame to request an appeal, typically within 60 to 65 days from the date of the initial denial notice. The insurance company must provide their decision within 72 hours of receiving your request for an expedited appeal.
If your expedited appeal is denied, you can proceed to the next levels of the appeal process, which may include an external review by an independent third party or a hearing before an Administrative Law Judge (ALJ). Each level of the appeal process has its own specific procedures and requirements, so be sure to carefully review the information provided by your insurance plan and seek assistance if needed.
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Appealing to the Office of Medicare Hearings and Appeals
If your health insurance company refuses to pay a claim, you have the right to appeal the company's decision. While the process can be time-consuming and daunting, it is often successful, with more than 50% of appeals of denials for coverage or reimbursement being approved.
If your health insurance denied your claim, you can start the appeals process, which typically has three levels. The first level of appeal involves requesting that your insurance company reconsider its decision. You or your doctor can make this request, and your doctor may also request a "peer-to-peer insurance review" to challenge the decision.
If your first-level appeal is denied, you can move on to the second level of appeal, which involves an external review by an independent third party. This is called an external review organization (ERO) and is guaranteed under the Affordable Care Act.
If your request is still denied after the first two levels of appeal, you can move on to the third level of appeal, which is a decision by the Office of Medicare Hearings and Appeals (OMHA). To file an appeal with OMHA, your case must meet a minimum dollar amount. For 2024, this amount was $180, and it increased to $190 for 2025.
You can request a hearing before an Administrative Law Judge (ALJ) or, in certain circumstances, you can ask for an on-the-record review of your appeal by an ALJ or attorney adjudicator without a hearing. To request a hearing before an ALJ, follow the directions on the "Medicare Reconsideration Notice" you received from the Qualified Independent Contractor (QIC) in your second-level appeal. An ALJ hearing is usually held by phone or video teleconference, but it can also be held in person if the ALJ finds that you have a good reason.
If OMHA does not issue a decision within the specified time frame, you may request that your appeal be escalated to the Medicare Appeals Council. If you disagree with the Appeals Council's decision, you have 60 days to request a judicial review by a federal district court, as long as your case meets a minimum dollar amount. For 2024, this amount was $1,840.
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Knowing your rights to appeal
If your insurance company refuses to pay for your medication, you have the right to appeal the decision. While it can be time-consuming to deal with, many health insurance denials may be resolved through the insurance appeals process.
The appeals process has some common elements across all health plans, but it's important to check your plan's specific process and required information. You can find this information in your policy documents or on your plan's website. If you have a plan provided by your employer, you can check with your human resources department or the member handbook you were provided when you enrolled. If you have Medicare coverage, check your Medicare & You handbook for the specific process.
When you file an appeal, you are asking your insurance company to reconsider its decision to deny covering a medication, treatment, or service. The first step in an appeal is called an internal review. It begins when you file an appeal of a denied claim. Your claim will get a second look by insurance company employees who weren't involved in the original decision. If you are in an urgent medical situation, you can request an expedited appeal, which requires the insurance company to make a decision within 72 hours.
There are two ways to appeal a health plan decision: Internal appeal and External review. If your claim is denied or your health insurance coverage is canceled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
External review means that the insurance company no longer gets the final say over whether to pay a claim. You have the right to take your appeal to an independent third party for review. This is guaranteed under provisions of the Affordable Care Act. Every state and every insurance company offering coverage must provide access to an independent external review process.
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Frequently asked questions
If your insurance company refuses to pay for your medication, you can ask for an exception. If that doesn't work, you can appeal the coverage decision.
You can start the appeals process by requesting an internal review. This involves asking your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
The internal review process begins when you file an appeal of a denied claim. Your claim will get a second look by insurance company employees who weren't involved in the original decision.
If your internal appeal is denied, you have the right to take your appeal to an independent third party for an external review. This means that the insurance company no longer has the final say over whether to pay a claim.
It is important to be persistent and not give up. Many times, patients who are initially denied eventually get approved for the coverage they need. Additionally, seek help from your doctor or hospital, as they can provide letters or statements explaining the medical necessity of the medication or treatment.
