Please note, some plans may have multiple levels of internal appeals. This can include a peer review where the plan will contact a doctor who is not involved in your care to review the claim.

Phase 3 - External Appeal

If your health insurance company denies your internal appeal, you can request an external appeal to an independent review organization. This is available for individual, and employer-sponsored health insurance plans.

The appeals process will depend on your health insurance company, so contact them for details or look for instructions on how to file an appeal on your denial letter.

Timing of Internal Appeals

Depending on what type of appeal, pre-authorization or post-treatment, there are time frames related to filing an internal appeal:

Type of Appeal

Pre-Authorization Appeal

Post-Treatment Appeal

Urgent Care (or Expedited Appeal)

Reason for Appealing

Denial prevented patient from receiving care.

Denial for payment of care received. Patient is 100% responsible for any charges.

Delay in treatment would seriously jeopardize life/overall health, affect your ability to regain maximum function, or subject you to severe and intolerable pain

When to Submit Appeal

Within 180 days

Within 180 days
But if urgent, can ask for external review at the same time as internal review

Timeline for Decision from Insurance Company

Within 30 days of initial appeal

Within 60 days of appeal

Within 72 hours of receiving appeal

Timing of Internal Appeals

Depending on what type of appeal, pre-authorization or post-treatment, there are time frames related to filing an internal appeal:

Types of Appeals:

Pre-Authorization Appeal

Reason for Appealing:
Denial for payment of care received. Patient is 100% responsible for any charges.

When to Submit Appeal
Within 180 days

Timeline for Decision from Insurance Company*
Within 60 days of appeal

Post-Treatment Appeal

Reason for Appealing:
Denial for payment of care received. Patient is 100% responsible for any charges.

When to Submit Appeal
Within 180 days

Timeline for Decision from Insurance Company*
Within 60 days of appeal

Urgent Care (or Expedited Appeal)

Reason for Appealing:
Delay in treatment would seriously jeopardize life/overall health, affect your ability to regain maximum function, or subject you to severe and intolerable pain

When to Submit Appeal
Within 180 days
But if urgent, can ask for external review at the same time as internal review

Timeline for Decision from Insurance Company*
Within 72 hours of receiving appeal

Steps to take

Understand the Reason for Denial

There are many reasons your health insurance company may deny coverage for your medical care, including:

Mistakes
Can occur with your billing details, or how your doctor submits a claim to your insurance.

Pre-Authorization
Insurance companies may deny coverage if you did not get a pre-authorization.

Service Not Covered
The service that you received is not included in your insurance plan.

Understand Your Plan’s Appeals Process

Your health insurance company may have their own internal appeals process. Contact them for details or look for instructions on how to file an appeal on your denial letter.
Get a copy of your file from the insurance company and request any decision they make in writing.

Work with Your Health Care Team

Your health care team, can support you in many ways through the appeals process – they may even file the appeal for you!
If you are submitting the appeal, get a letter of support from your health care team including the reasons why it is medically necessary for you to get the care that they have provided.

Gather Information

Include all of the information requested by the insurance company.
For instance, the member’s name and identification number, the name of the health care provider who will or has provided the care, the dates of service, the claim reference number for the specific decision being appealed, and the specific reason why the care should be covered.

Stay Organized and Pay Attention to Deadlines

Staying organized and keeping track of deadlines is important in the appeals process. Here are a few things that you should keep track of when communicating with your insurance company:

Dates and method(s) of any contact (phone, email, etc.)
Names of the people you talk to
Summaries of your conversations (take notes)
Any documents you send or receive (save copies)

Be Patient and Persistent

You may have to go through several levels of appeals before your care gets approved.
It is likely worth it to stick with it and continue to get support from your health care team.

Additional Information

For additional information on appeals and the appeals process, visit Triage Cancer’s module on Health Insurance Appeals:
https://triagecancer.org/cancer-finances-appeals

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Disclaimer: The information on this site is intended for U.S. residents only and is provided purely for educational purposes. Health, legal, regulatory, insurance, or financial related-information provided here is not comprehensive and is not intended to provide individual guidance or replace discussions with a healthcare provider, attorney, or other experts. All decisions must be made with your advisers considering your unique situation. © Triage Cancer & Pfizer Inc. 2024

Appealing Denials of Coverage

Appeal Process Overview

Phase 1 - Denial of Coverage