Appeal and Review
A request for your health insurance company or the Health Insurance Marketplace to review a decision that denies a benefit or payment.
• If you don’t agree with a decision made by the Marketplace, you may be able to file an appeal. You can also appeal decisions by the SHOP Marketplace for small businesses.
• If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.
• Insurers have to tell you why they’ve denied your claim or ended your coverage.
• You can ask that your insurance company reconsider its decision.
• Insurers have to tell you know how you can dispute their decisions.
Your right to appeal
There are two ways to appeal a health plan decision:
♦ Internal appeal: If your claim is denied or your health insurance coverage cancelled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
♦ External review: You have the right to take your appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.
• Internal Appeals
• What papers do I need?
• What kinds of denials can be appealed?
• How long does an internal appeal take?
• What if my care is urgent and I need a faster decision?
• Types of denials that can go to external review
• What are my rights in an external review?
• How do I learn more about my state’s external review?
• How long does an external review take?
• Can someone file an external review for me?
• How much does an external review cost?