Your insurance claim was denied — how appeals actually work

A denial letter reads like a closed door. It is not one. It is the first step of a process that insurers are required to offer you — and a meaningful share of people who use it get a different answer.

Two things are true at once: most people never appeal, and appealing costs you nothing but time. Those facts are related. Insurers are not counting on you being wrong; they are counting on you not writing back.

Before anything else, find out why

Every denial has a stated reason, and the reason determines your entire strategy. Look for it on the denial letter or the EOB, usually as a short phrase with a code beside it. The common ones fall into a few families:

• Administrative. Wrong member ID, wrong date of birth, a digit off in a code, the claim sent to the wrong plan. These are the easiest to overturn and often need only a corrected resubmission, not a formal appeal.
• Not medically necessary. The plan is disputing whether you needed the care. This one is won with clinical evidence from the person who treated you.
• Prior authorization missing. Approval was required and not obtained. Worth checking who was responsible for obtaining it — frequently the provider, not you.
• Out of network, or not a covered benefit. Here you are arguing about the terms of the plan itself, so get the plan document.
• Experimental or investigational. The most involved category, and the one where external review matters most.

The two levels of appeal

For most plans there are two stages, and you generally have to use them in order.

1. Internal appeal. You ask the insurer to reconsider its own decision. Under the rules described on HealthCare.gov, you generally have 180 days from the denial notice to file, and the plan must give you a decision within set timeframes — faster for care you have not received yet than for a bill you already have.

2. External review. If the internal appeal fails, an independent reviewer outside the insurance company looks at the case. This is the part people underestimate: the insurer does not get to decide this one, and the decision binds them.

What actually makes an appeal work

Appeals are not won by expressing how unfair the denial is. They are won by addressing the stated reason with evidence, and by being easy to say yes to.

1. Answer the reason they gave, not the reason you suspect. If they said “not medically necessary,” every sentence should be about medical necessity.
2. Get a letter of medical necessity from your doctor. This is the highest-value item in most appeals, and most physicians’ offices have written many. Ask specifically for one that references your diagnosis, what was tried before, and why this treatment was indicated.
3. Quote the plan document where you can. If the plan covers something and the denial says otherwise, cite the page.
4. Keep it short and dated. One page, the claim number at the top, a clear request at the end.
5. Send it so you can prove it arrived, and keep a copy of everything.

What to say when you call

If the appeal fails

A denial that survives both levels is not the end of your options either. The bill still exists, and the tools that apply to any large medical bill apply to this one — asking the hospital for its financial assistance policy, requesting an itemized bill, and negotiating a payment plan. Those are separate paths, and they do not require the insurer to agree with you.

Where Mareva fits

Mareva reads a denial letter, explains in plain language exactly what was denied and why, points out the deadline sitting inside the letter, and drafts the appeal for you to review, sign and send yourself — in any of ten languages, with the letter written in English for the people who will read it. The first scan is free.