Insurance denials and appeals
A denied claim is not the last word. You can appeal to your plan and then ask for an independent review.
Checked against official sources: October 30, 2026.
Internal appeals
- You must file an internal appeal within 180 days (6 months) of the notice that your claim was denied. The plan must decide within 60 days for care you already got and 30 days for care you have not yet received (72 hours if urgent).
Law: 45 CFR 147.136(b); HealthCare.gov
Independent external review
- After a final denial, you can ask for an external review by an independent reviewer within 4 months. A standard review is decided within 45 days, an expedited one within 72 hours.
Law: 45 CFR 147.136(c), (d); HealthCare.gov
- Many states have a Consumer Assistance Program that helps with health insurance problems for free.
Law: CMS, Consumer Assistance Program
Medicaid and other public coverage
- If you qualify for Medicaid, it can pay for covered care you got up to 3 months before the month you applied, if you were eligible then. For applications made on or after January 1, 2027, this changes to 1 month before the month of application for adults in the Medicaid expansion group and 2 months for others.
Law: 42 U.S.C. 1396a(a)(34), 1396d(a); Pub. L. 119-21, sec. 71112 (July 4, 2025)
- Providers in the Medicaid program must accept Medicaid's payment plus any copay or deductible the program sets as payment in full.
Law: 42 CFR 447.15
- If you are in the Qualified Medicare Beneficiary (QMB) program, Medicare providers may not bill you for Medicare deductibles, coinsurance or copays for Medicare-covered care.
Law: 42 U.S.C. 1396a(n)(3)(B); CMS
If the problem is a surprise charge
- With most private health plans (job-based plans, Marketplace and other individual plans), you are protected from surprise out-of-network bills for emergency care, for non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgical center, and for air ambulance services.
Law: 42 U.S.C. 300gg-111, 300gg-131, 300gg-132, 300gg-135
- For protected services, you can't be charged more than your in-network cost-sharing (copay, coinsurance, deductible).
Law: 42 U.S.C. 300gg-131, 300gg-132
Where to get help
- Call the help desk with questions or to complain if a provider or insurer did not follow these rules. Help is available in English, Spanish and over 350 other languages.
Law: 42 U.S.C. 300gg-111, 300gg-131, 300gg-132, 300gg-135
Your state insurance department: complaint contacts by state
Before you act
Ask your plan for the denial in writing, with the reason and the deadline to appeal. Gather the bill, the explanation of benefits and any letter from your doctor, and write down the date and name of everyone you speak with.
Quick answers
How do I appeal a denied claim?
You must file an internal appeal within 180 days (6 months) of the notice that your claim was denied.
Can I get an independent review?
After a final denial, you can ask for an external review by an independent reviewer within 4 months.
Can Medicaid cover bills from before I applied?
If you qualify for Medicaid, it can pay for covered care you got up to 3 months before the month you applied, if you were eligible then.
Free help
Free help can look at your bill and your letters. Legal aid groups, state insurance departments and the federal help desk do not charge for this.