Step 1: Understand Why You Were Denied

First, you need to understand why they are not paying. Let’s read your Explanation of Benefits (EOB) or denial letter carefully. Common reasons include missing prior authorization, out-of-network provider, lack of medical necessity, policy exclusions, or coding errors. Do you see the language about the reason for denial? This is very important … so if you (like many of us!) cannot understand why the insurance company is denying you, you can simply call them and speak to someone who can explain why this particular care (drug) was denied. Calling the insurance company to find out the reason for denial may even solve your problem, if the denial was due to an error such as wrong patient information, wrong treatment or service date.

Step 2: Know Your Appeal Rights (and Deadlines!)

If you go all the way to the bottom of the denial letter you can (hopefully!) read about your appeal rights.Yes, while insurers are required to actually tell you how to appeal, many denial letters miss this information (wonder if it’s on purpose..). If you see the “how”and "when” to appeal you denial - great! If not, you can simply call the insurance company and speak to someone who can explain how to appeal or when the deadline is. You usually have between 30 and 180 days from the date of denial to submit your appeal — depending on your plan. You have the right to appeal any health insurance denial. This right is guaranteed under federal law through the ACA and ERISA.

If you still don’t have the appeal information, I posted here many resources and videos on how to find more information about appealing a denied health insurance claim. Reading your health insurance policy should also provide you with the information on how to appeal denied claims.

Deadlines are important, so if you tend to put off reading your mail (that looks like bills and not checks … guilty here! :)) you may want to go grab it and open it now. Insurance companies like to give deadlines for appeals because if we miss them, they have a great excuse to deny! So.. please don’t let them win this time, let’s get it done now.

Step 3: Get Your Evidence

The stronger your evidence, the higher your chances of winning. Here, depending on the reason for denial, collect applicable doctor's letters, test results, prior authorizations, and medical research material. Do you need all that to persuade the insurance company to pay for your treatment? Ideally, you want to try and get as much evidence as possible to show why your claim should be paid. But even if you gather some (and not all) documents, it is better than sending nothing at all with your appeal. The first step is calling your doctor and asking for a letter explaining why this care/drug was prescribed to you, why you need it, why and how other treatments failed (if you tried other treatments). Maybe the office can email it to you for faster results. I’m sure you are always polite, but be extra polite on the phone with your doctor’s office and they may expedite your request !

Including medical research material is very useful. When you research, try to use reliable medical sources.You can watch my video explaining what it means for the purposes of your appeal. Add the medical research to your appeal as evidence of how the prescribed treatment is standard care for your condition.

Step 4: Write a Persuasive Appeal Letter

I love writing, but I can imagine that it may be hard for someone who is not into it. The thing is you have to write your appeal - there is no way around it. My advice is not to be emotional here. Write a clear statement ('I am appealing your decision to deny ….. because…) and explain why the service should be covered. Be polite, ask them to reconsider. If you need help writing, go to my appeal templates and choose one appeal letter that fits your denial. I wrote customizable appeal letter templates for many denial reasons and you can use it and simply fill in the blanks with your information.

When I write my appeals, I sound very professional, concise, polite but the tone is very assertive (my code word for aggressive). It is because we are not begging, we are stating the fact that the claim should have been paid in the first place and if it is not paid on appeal, you know your rights and you will push forward until it is paid!

Include in your letter: Your Policy Information, Your Name, Insurance Company, Member ID / Claim #, Date of Service, Denial Reason, Appeal Deadline, Date Appeal Sent On.

If your appeal is urgent, you need to write in large letters “URGENT” 2-4 times on all pages of your letter to make sure that the appeal specialist (let’s hope it’s a human and not AI) sees the word “urgent” and knows it should be handled in an expedited manner.

Step 5: Send It (and Track Everything)

The denial letter should tell you how to send your appeal. Is it online? Via fax or mail? Always keep copies. I have been dealing with insurance companies for over a decade and I have seen every excuse about why they never received an appeal (lost mail, email didn’t get through, the fax is fuzzy, etc.). That’s why my recommendation is to send it via as many channels as possible - certified mail, fax, email or through your insurer’s online portal. Absolutely remember to track delivery. Save the return receipt from certified mail, successful fax transmission, or online portal submission verification. A good strategy is calling the insurance company in 2-4 days to make sure they have your appeal. If they don’t have it (why am I not surprised), tell them you have proof of delivery and want to re-submit, but this time ask them for a more reliable way to resubmit (like someone’s email) since you already lost 2-4 days.

Send your appeal to your state’s department of insurance.

Write a brief cover letter explaining why you want the DOI to review your appeal (mmm… because you don’t trust that your claim was reviewed properly or that the treatment is urgent).

Once you submit your appeal:

• Your internal appeal must be reviewed within 30–60 days.

• If urgent, you can request an expedited appeal (decision within 72 hours).

• If denied again, you can immediately request an external review — a truly independent process where medical experts review your case.

You still have the right to appeal again externally even if the insurer upholds their denial. This right cannot be taken away.

You deserve fair treatment. Your insurer must follow the law — and you have the right to appeal every denial. With persistence and clarity, you can turn a 'No' into a 'Yes.'

💪 You Can Win — Don’t Give Up

Most people assume insurers never reverse their decisions — but that’s not true. Studies show that 40–60% of appeals are successful when patients provide detailed letters and medical documentation.

That’s why I created ready-to-use, professional appeal letters.You fill in your details, attach your evidence, and send it. It saves hours and increases your chances of success.

👉 Explore Templates for:

• Denied for “medical necessity”

• Denied for “lack of prior authorization”

• Denied for “out-of-network”

• Denied for “policy exclusion”, “not covered by policy”, or “exceeds policy limits”

• Denied for “experimental or investigational treatment”

Life lesson I learned: When I was thinking about going to law school, I decided to get a job at a law firm to see if law was something I wanted to do. I was shocked to see how stressful and demanding the career of a lawyer is! But with that I also saw happy grateful clients whose lives were literally changed with the help of an attorney (yes, they did complain about legal fees later..). But the attorney I worked for gave me a great piece of advice: “Go to law school even if it is hard, because being an attorney makes you also an educated consumer for life.” I often think about it. If we all were educated consumers, insurance companies would not be able to take advantage of us so often! With Appeal Templates, I want you to become an educated consumer. Yes, it is hard to do all the learning, digging and researching, but it does pay off! Today let’s start the journey with appealing your denied claim.

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Disclaimer

Appeal Templates LLC is not a law firm and does not provide legal advice. This guide is for informational and self-help purposes only.

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