How to File an External Appeal When Your Health Insurance Claim Is Denied (2025 Guide)
If Your Health Insurance Claim Was Denied, You’re Not Out of Options
When a health insurance company denies coverage for treatment, most people assume they have no choice but to accept the decision. It’s frustrating, confusing, and often emotionally draining — especially if you’re dealing with a serious or ongoing medical condition.
But here’s the truth many patients never hear:
👉 You have powerful rights to challenge the denial — including the right to an independent, third-party “external appeal.”
Few people use this option, even though it can be life-changing. A recent investigation highlighted how an external review helped overturn a denial for a North Carolina family after a series of devastating mental health crises. Their insurer had denied vital psychiatric care multiple times. Still, an external reviewer — completely independent from the insurance company — overturned the decision, saving the family more than $70,000.
Stories like this underscore a simple lesson, often repeated by advocates and policy experts:
ALWAYS APPEAL. You have more power than you think. GET STARTED WITH MY FREE APPEAL GUIDE HERE.
This guide explains what external appeals are, who qualifies, how to file, and how to give yourself the strongest chance of success.
What Is an External Appeal?
An external appeal (also known as an external review) is a process where an outside, independent medical expert reviews your insurance denial to decide whether the insurer must pay for your treatment.
This reviewer:
Is not employed by your insurance company
Is not influenced by the plan
Must meet strict conflict-of-interest rules
And most importantly:
👉 If the external reviewer overturns the denial, your insurer must legally pay for the treatment.
This decision is binding. Insurance companies cannot ignore or override it.
External appeals have existed at the state level for decades, but the Affordable Care Act expanded them nationally, giving most people with employer-based or marketplace coverage the right to an external review.
Why External Appeals Are Underused
Despite their power, external appeals remain one of the biggest “hidden” rights in the health insurance world.
Only a tiny fraction of eligible patients ever file one.
Why? Several reasons:
1. Many people don’t know they exist.
Information is often buried deep in denial letters — sometimes as far down as page seven.
2. Patients feel exhausted and overwhelmed.
Battling an illness or caring for a loved one makes fighting an insurance company feel impossible.
3. Instructions are confusing or incomplete.
Many denial letters are unclear, and they rarely explain how to file an appeal in plain language.
4. Some states offer strong consumer assistance programs — others offer none.
Programs in states like Maryland, Connecticut, and New York help patients navigate appeals and overturn many denials. But about 20 states still offer no clear guidance on how to file an external appeal.
5. People think insurers never reverse their decisions.
But that’s simply not true. When patients appeal — especially when they gather strong evidence — denials are frequently overturned.
For example:
Connecticut’s Health Care Advocate Office resolves or overturns about 80% of the external appeals it handles.
Research from KFF shows internal appeals overturn a significant number of denials.
And external reviews, when eligible, give patients one of the strongest chances of success.
What Types of Denials Qualify for an External Appeal?
Not every denial qualifies — but many important ones do. Usually, if you filed an internal appeal and it was denied, the insurance company will send a denial letter outlining your further steps on how to file an external appeal.
You may be eligible for an external appeal if your denial involves:
Medical judgment (insurer says treatment isn’t medically necessary)
Clinical decisions
Experimental or investigational treatments
Surprise medical bills
Retrospective cancellations of coverage (“rescissions”)
These are exactly the types of denials where independent review is most powerful.
❌ Denials that usually do NOT qualify:
When your plan simply doesn’t cover the service
When the plan requires an internal appeal first and you have not filed it yet
However, if you’re unsure whether your denial qualifies, you can always request clarification or file the request anyway — plans are required to tell you if you are eligible.
Before You Can Request an External Appeal: You Must Try an Internal Appeal First
In most cases, you must complete your internal appeal — your chance to ask the insurer to reconsider — before “escalating” to an external review.
Internal appeals often include:
Level 1 appeal: A fresh review within the insurance company
Level 2 appeal: A second internal review option for some plans
Only after you’ve “exhausted” internal appeals can you request an external appeal.
However:
👉 If your situation is urgent or life-threatening, you can request an expedited external appeal without completing internal appeals first.
Step-by-Step: How to File an External Appeal (2025 Guide)
Step 1: Gather all your documents
Collect:
Your denial letter (“adverse benefit determination”)
Plan documents
Explanation of Benefits (EOBs)
Any previous appeal letters
Medical records
Support letters from your doctor
Proof of medical necessity
Bills or statements
If you lost anything, your insurer must provide additional copies upon request. For my legal tips on how to write a winning appeal click here.
Step 2: Check if your state has a consumer assistance program
About 30 states have Consumer Assistance Programs (CAPs) that will:
Explain your denial
Help you understand the rules
Assist you in filing internal and external appeals
Communicate with insurers on your behalf
Write or help prepare your appeal package
Their services are free.
If your state has no program, nonprofit organizations in your area may help. I would also recommend sending an external appeal to your state’s department of insurance. I have prepared a list of contact information for all 50 state Departments of Insurance. Get it here.
Step 3: Confirm your deadlines
Deadlines matter. Most plans give you:
180 days from the date of denial to file your internal appeal
After completing internal appeals, a separate window to request an external review (usually included in the notice)
Don’t wait. Many people lose their rights simply because they missed the deadline.
Step 4: Call your insurer and ask key questions
When you call, ask:
Why was my claim denied?
Is this denial eligible for an external review?
Which rules apply — state or federal?
What forms do I need to file?
Where do I submit my external appeal request?
Under federal rules, insurers must provide clear answers. For my legal tips on how to speak to the insurance company click here.
Step 5: Submit your internal appeal
Even though the insurer conducts this stage internally, your appeal should be:
Detailed
Supported by medical evidence
Backed by your provider
Clear about medical necessity
For my legal tips on how to submit your appeal click here.
Step 6: File your request for an external appeal
Once your internal appeals are exhausted:
Contact your insurer to request an external review.
They must respond within 5 days to confirm eligibility.
You will receive instructions on where and how to file.
Submit all documents requested.
External review entities typically have 45–60 days to make a decision. For my legal tips on how to request an external appeal click here.
Expedited External Appeals
If waiting 45–60 days would seriously harm your health, you can request:
An expedited external review, with a decision in 72 hours
In some cases, you can request internal and external reviews at the same time
What Happens After You File an External Appeal
A neutral medical expert or panel reviews your case and decides whether the insurer must cover your treatment.
If the reviewer overturns the denial:
👉 Your insurer is legally required to pay for the treatment.
👉 The decision is binding — the insurer must honor it.
👉 You cannot be charged more because you appealed.
If the reviewer upholds the denial:
You still have other options:
A state complaint
A regulatory complaint
A lawsuit
Help from a nonprofit or consumer advocate
State Examples: How Better Laws Help Patients
Some states have taken steps to make the process clearer and more accessible.
Maryland
Denial letters must include appeal rights at the top of the page in bold print. Result: More patients use their appeal rights.
Connecticut
Added clear instructions in a boxed notice on page one of all denial letters. Outcome: Over 40% of referrals now come from these improved notices. Their external appeal overturn rate is around 80%.
New York
Tracks and publishes external review outcomes online, improving transparency and public trust.
Experts All Agree on This: Don’t Give Up
People often feel too overwhelmed or discouraged to fight a denial — especially during major illnesses such as cancer, chronic conditions, or mental health crises. But experts who work with patients say the biggest issue is simply not knowing the system exists.
Your rights are real, and they are strong.
As one advocate said:
“The insurance companies know people don’t appeal — and they count on it.”
But when you do appeal, and especially when you request an external review, you dramatically increase your chances of getting coverage. For my legal tips on how to write a winning appeal click here.
How a Strong Appeal Letter Can Make a Difference
Your appeal letter matters — both internally and externally.
A strong letter should:
Clearly explain why the denial is wrong
Cite medical evidence and guidelines
Include letters from your provider
Identify misunderstandings or missing information
Address medical necessity head-on
If writing your own appeal feels overwhelming, using a professionally structured template can make the process much easier.
You Have More Rights Than You Realize
External appeals are one of the most powerful protections available to patients — yet one of the least used. They can overturn costly, life-altering denials, and they exist to ensure that independent medical judgment — not bureaucracy — determines your care.
If your claim was denied:
✔ Don’t accept it as the final word.
✔ Appeal internally.
✔ Request an external appeal when eligible.
✔ Ask for help — you do not have to navigate this alone.
Need Help Getting Started?
Get FREE Appeal Guide Here.
Writing an appeal letter is one of the biggest hurdles for patients — so I created professional attorney-written Appeal Letter Templates that take the guesswork out of the process.
You can browse templates for:
Medical necessity denials
Experimental or investigational treatment denials
Out-of-network denials
Prior authorization denials
Mental health treatment denials
And more
👉 Visit appealtemplates.com/shop to download the exact template you need.
With the right information — and the right tools — you can fight back and win.
