Is your situation covered?
| Scenario | Typical verdict | Why |
|---|---|---|
| Prior authorization not obtained | Depends on wording | Retroactive auth possible for emergencies; elective procedures much harder. |
| Out-of-network provider without emergency status | Depends on wording | No Surprises Act protects true emergencies, anesthesia, radiology at in-network hospitals. |
| 'Not medically necessary' | Depends on wording | Highest reversal rate on appeal — 50%+ with physician documentation. |
| Coding error (wrong CPT/ICD-10) | Usually covered | Nearly always resubmitted successfully; ask provider to rebill. |
| Service excluded from plan | Usually not | Cosmetic, experimental, or explicitly excluded services rarely overturn on appeal. |
| Coverage lapsed / not effective on service date | Usually not | Fix at the eligibility level, not the claim level. |
General industry patterns. Your actual cover lives in your policy wording — PolicyPal reads it for you.
The short answer
Roughly 1 in 7 US health insurance claims is initially denied, and the ACA gives every plan member the right to a full internal and external appeal. Studies show 40–60% of appealed denials are overturned — meaning most denials are worth challenging. The trick is identifying the exact denial code and matching your response to it.
Read the EOB, not the bill
Every denial has a CARC (Claim Adjustment Reason Code) and RARC (Remittance Advice Remark Code) on your Explanation of Benefits. These tell you exactly why the insurer refused to pay and what evidence they need. Do not appeal blind — request the denial letter that includes clinical review notes.
- Get CARC/RARC codes from the EOB
- Request clinical review notes if 'not medically necessary'
- Verify CPT and ICD-10 codes with the provider's billing
- Check plan documents (SPD/EOC) for the exclusion cited
The appeal timeline
Standard internal appeal window is 180 days from denial. Insurer must decide within 30 days (pre-service), 60 days (post-service), or 72 hours (urgent). If denied again, request external review — independent, binding, free, and overturns 40%+ of denials.
- Level 1: internal appeal (write and submit within 180 days)
- Level 2: second-level internal appeal (some plans)
- Level 3: external review by an Independent Review Organization
What PolicyPal checks
We read your Summary Plan Description and policy certificate, match the denial code to the exact plan provision, identify prior-auth and medical-necessity language, and draft an appeal outline citing the plan's own definitions. We also flag whether the No Surprises Act, ERISA claims regulations, or state law provide additional leverage.
Common mistakes on appeal
Patients lose appealable denials by missing the 180-day window, appealing without the denial letter, failing to attach a physician letter of medical necessity, and confusing internal appeal with external review. Request an expedited review any time delay would jeopardize health.
Frequently asked
- How do I appeal a health insurance denial?
- Read the EOB for the denial code, request the full denial letter, submit a written internal appeal within 180 days with supporting documentation, and if denied again request external review.
- Does the No Surprises Act apply?
- Only for emergencies, out-of-network providers at in-network facilities, and air ambulance. It doesn't cover routine out-of-network care or ground ambulance.
- Can my doctor appeal for me?
- Yes — physicians can file 'peer-to-peer' appeals directly with the insurer's medical director, especially effective for 'not medically necessary' denials.
- What if the appeal is denied twice?
- Request external review by an Independent Review Organization (IRO). Decision is binding on the insurer. Free to you.
- How long does an appeal take?
- 30 days pre-service, 60 days post-service, 72 hours if expedited (urgent care needed). External review adds 45 days (72 hours expedited).
- Do I have to pay the bill during the appeal?
- No — the balance is not due until appeals conclude. Notify the provider in writing that a claim is in dispute.
- Is a HIPAA appeal different from a plan appeal?
- Yes — HIPAA governs privacy, not claim decisions. Use the plan's ERISA or state-mandated appeal process for denials.
Your policy is the only source of truth
Stop guessing. Check your actual policy.
Generic answers don't pay claims. PolicyPal reads your policy wording in seconds and tells you, in one sentence, whether you're covered.