Frequently asked questions

An appeal is your formal request that your insurer reconsider a denied claim. Under the Affordable Care Act, every insured American with a non-grandfathered plan has the right to at least one internal appeal and, if that is denied, an external review by an independent organization.

Under federal law, you generally have 180 days from receiving the denial notice to file an internal appeal. Some plans allow longer; some allow less. The exact deadline will be stated on your denial letter. Check it as the first thing you do — missing the internal-appeal window usually forfeits external review as well.

According to Kaiser Family Foundation analysis of HealthCare.gov plans, denials cluster around five main reasons: administrative or coding issues (about 18% of denials), services excluded under the plan (about 16%), missing prior authorization or referral (about 9%), services determined not medically necessary (about 6%), and a large 'other' category (about 34%). Each requires a different appeal strategy.

Often yes. Providers and patients have different leverage in an appeal. A provider letter alone is rarely the strongest possible appeal — the strongest appeals combine a treating-provider letter, your own statement of impact, plan-language citations, and (for medical necessity) peer-reviewed support. If your provider's office is filing alone, ask whether they're including all of these elements.

An internal appeal is the insurer reviewing its own original decision. An external review is conducted by an independent organization (called an Independent Review Organization or IRO) outside the insurer. External review decisions are binding on the insurer. You generally must complete internal appeal first before requesting external review.

Plans define medical necessity in their plan documents, but the general standard is: a service that is consistent with generally accepted standards of medical practice, clinically appropriate for the patient's condition, and not primarily for the convenience of the patient or provider. The standard is plan-specific; the same service can be 'medically necessary' under one plan's language and not under another's.

CARC stands for Claim Adjustment Reason Code — a standardised code your insurer uses to tell you why a claim was adjusted or denied. CARC codes appear on your Explanation of Benefits (EOB) and on most denial letters. Common ones include CARC-50 (not medically necessary), CARC-197 (prior authorization absent), and CARC-204 (service not covered under the plan).

If you're inside the appeal window stated on your denial letter (usually 180 days), yes. If you're past it, the answer is harder — some plans allow good-cause exceptions, and some states have rules about insurers' obligations even outside the standard window. Run the free triage and we'll tell you whether your case is still within scope.

For most consumer health-insurance appeals, no. Internal appeals and external review are administrative processes designed to be navigable by consumers. Lawyers become valuable when the dispute involves ERISA litigation, alleged bad faith, large damages, or disability claims. We are not a law firm and don't provide legal advice; if your case has any of those characteristics, we recommend consulting an ERISA or insurance lawyer.

Self-funded employer plans (where your employer pays claims directly rather than an insurer) are regulated by federal ERISA rules rather than state insurance law. They still have appeal rights, and we support them, but external-review procedures can differ — some self-funded plans use the federal HHS-administered external review process instead of state-level processes.

Filing yourself is absolutely possible and we publish free guides to help you do it. What we add is: speed (24-hour preparation), structure (a professionally-formatted appeal that addresses each element insurers look for), citations (specific plan-language references for Premium tier), and human review by a named medical-claims specialist. If you're confident and have the time to research it yourself, the free guides may be all you need.

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