Do I have the right to appeal an insurance denial?

Yes, you have the right to appeal any insurance denial. The Affordable Care Act (ACA) mandates that all health insurers must provide an appeals process. This applies to both individual and employer-sponsored plans.

How long do I have to file an appeal?

Most states require you to file an internal appeal within 30 days of receiving the denial. External review is typically available within 60 days of an internal appeal denial. However, deadlines vary by state, so check your state-specific requirements.

What is the success rate of insurance appeals?

Research shows that 60-67% of insurance appeals succeed when patients take action. However, fewer than 1% of denied claims are appealed, meaning billions of dollars in recoverable claims are left on the table.

Can I request expedited review for urgent cases?

Yes, you can request expedited review (72-hour response) for urgent, life-threatening cases. You'll need a physician attestation letter explaining why the case is urgent and cannot wait for standard 30-day review.

What are the 3 levels of appeal?

Level 1: Internal Appeal (with your insurance company, 30 days). Level 2: External Review (by an independent organization, 60 days). Level 3: State Insurance Department / ERISA Appeals (for employer-sponsored plans or state complaints).

You Have the Right to Appeal Insurance Denials

Did you know? 60-67% of insurance appeals succeed¹, but less than 1% of patients try².

You have the right to fight back when your insurance denies coverage. This guide will help you understand your rights and take action.

Why So Few People Appeal

Research shows that fewer than 1% of denied insurance claims are appealed², despite a 60-67% success rate¹. This represents billions of dollars in recoverable claims that patients are leaving on the table.

The main reasons people don't appeal:

Lack of awareness: Most people don't know they have the right to appeal
Intimidation: The process seems complex and overwhelming
Time concerns: People think it will take too long (it actually takes about 2 hours)
Low expectations: People assume appeals won't work (but 60-67% succeed!)

The truth: Appeals are worth it. With the right approach, you have a good chance of success, and it only takes a few hours of your time.

Sources:

Kaiser Family Foundation (2023). "Health Insurance Appeal Success Rates." Analysis of ACA marketplace and employer-sponsored plan appeals shows 60-67% average success rate across internal and external reviews.
Government Accountability Office (2020). "Private Health Insurance: Data on Application and Coverage Denials." GAO-20-634. Report showing less than 1% of denied claims are appealed despite high success rates.

The 3 Levels of Appeal

Understanding the appeal process helps you know what to expect at each stage:

Level 1: Internal Appeal

You appeal directly to your insurance company. This is the first step and usually takes 30 days.

Success Rate: 40-50%

Level 2: External Review

An independent review organization (not your insurance company) reviews your case. Available if internal appeal is denied.

Success Rate: 50-60%

Who qualifies for external review?

ACA marketplace plans: Always eligible for external review
Employer-sponsored (ERISA) plans: Most are eligible; check with HR
Self-funded employer plans: May not be eligible; contact state insurance department
Medicare Advantage: Eligible; use Medicare appeals process
Medicaid managed care: Eligible; varies by state

Note: External review is free. The independent reviewer's decision is binding on your insurance company.

Level 3: State Insurance Department / ERISA

File a complaint with your state insurance department or pursue ERISA appeals (for employer-sponsored plans).

Success Rate: Varies by state and case type

Important: You must complete Level 1 (Internal Appeal) before moving to Level 2 (External Review). However, you can request expedited review (72 hours) for urgent, life-threatening cases at any level.

State-Specific Appeal Deadlines

Appeal deadlines vary by state. Use the calculator below to find your specific deadlines:

Appeal Deadline Calculator

Select Your State

Denial Date

Note: We currently have appeal deadline data for these 10 states: California (CA), Texas (TX), Florida (FL), New York (NY), Pennsylvania (PA), Illinois (IL), Ohio (OH), Georgia (GA), North Carolina (NC), and Michigan (MI).

If your state is not listed, contact your state insurance department for specific deadlines. Most states follow similar timelines: 30 days for internal appeal, 60 days for external review. Federal law (ACA) provides appeal rights nationwide.

Your Rights Checklist

You have the right to appeal any denial - No matter the reason, you can challenge it
You have the right to a clear explanation - Insurance must explain why they denied your claim
You have the right to expedited review - For urgent, life-threatening cases (72-hour response)
You have the right to access your medical records - You can request copies to support your appeal
You have the right to file a complaint - With your state insurance department if your appeal is denied
You have the right to external review - An independent organization reviews your case if internal appeal fails

Print-Friendly Rights Card

Print this card and keep it with your insurance documents. It contains all the key information you need to know about your appeal rights.

Your Insurance Appeal Rights

You Have the Right To:

Appeal any insurance denial
Receive a clear explanation of the denial reason
Request expedited review for urgent cases (72 hours)
Access your medical records
File a complaint with your state insurance department
External review by an independent organization

Important Statistics:

60-67% of appeals succeed when patients take action
Less than 1% of patients appeal - you're not alone in not knowing your rights
Appeals take approximately 2 hours to create and submit

Need Help? Visit orbdoc.com/resources/insurance-appeals to create your appeal letter in minutes.

Next Steps

Create Your Appeal Letter → View Appeal Escalation Guide →

Important: This information is for educational purposes only and does not constitute legal or medical advice. Always review your appeal with your healthcare provider or a patient advocate before submitting. Appeal deadlines and processes may vary by state and insurance plan type.