Healthcare Policy & Insurance Editor · Last reviewed January 2025
Insurance coverage denials are common — and they are not final. Federal law gives you the right to appeal any denial of coverage, and many appeals succeed. Understanding the appeals process and your rights is one of the most valuable things any patient can know.
Types of Denials
Coverage denials typically fall into one of several categories: medical necessity denials (the insurer determines the service isn't medically necessary); non-covered service denials (the insurer claims the service isn't a covered benefit); out-of-network denials; and concurrent review denials (the insurer approves a shorter duration of treatment than recommended). Each type may require a different appeal strategy.
The Internal Appeals Process
All plans subject to ACA requirements must provide a minimum two-level internal appeals process. Level 1: file a written appeal with your insurer within the timeframe specified in your denial notice (typically 180 days). Your appeal should include: a written statement from your treating clinician explaining why the denied service is medically necessary; the clinical documentation supporting that determination; and, for behavioral health denials, a parity analysis comparing the requirement applied to similar medical/surgical benefits.
Level 2: if the Level 1 internal appeal is denied, most plans provide a second-level internal review. The timeframes for decisions on appeals are regulated: 60 days for standard internal appeals, 72 hours for urgent/expedited appeals.
External Review
After exhausting internal appeals, you have the right to request external review by an independent review organization (IRO) — a third party with no financial relationship with your insurer. External reviewers are required to use clinical standards, not the insurer's proprietary criteria. External review is binding on the insurer — if the IRO overturns the denial, the insurer must cover the service. External review is free to the patient for most non-grandfathered plans.
Parity-Specific Appeals
For behavioral health denials, explicitly invoking MHPAEA parity in your appeal is important. Request from your insurer a written explanation of the specific coverage criteria and non-quantitative treatment limitations applied to the denied service, and compare them to the criteria applied to comparable medical/surgical benefits. If you can document that the insurer applies more restrictive requirements to behavioral health, you have a parity complaint in addition to an appeal.
Additional Resources
Your state insurance commissioner's office can provide information on state-specific appeal rights and accept parity complaints. Patient advocates — available through some hospitals, insurance brokers, and nonprofit organizations — can assist with complex appeals. Legal aid organizations can assist low-income patients with coverage disputes.
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