What percentage of insurance appeals are successful?

Studies consistently show that 40-60% of appealed claims are overturned. Despite this, fewer than 1% of denied claims are actually appealed. If your claim is denied, appealing is almost always worth the effort.

Can I appeal a claim more than once?

Yes. Most insurance plans allow at least two levels of internal appeal before you can request an external review. Each level is reviewed by different people, so new evidence or arguments can lead to a different outcome.

How to Appeal a Denied Insurance Claim: Step-by-Step

Why Claims Get Denied

Insurance claims are denied for many reasons: lack of prior authorization, the service was deemed not medically necessary, coding errors, the provider was out of network, timely filing deadlines were missed, or incomplete information on the claim. A denial does not mean you are responsible for the full bill — it means the insurance company needs more information or disagrees with the claim as submitted.

Step 1: Understand the Denial

Read the denial letter or EOB carefully. It should include a reason code or explanation of why the claim was denied, and instructions for how to appeal. Note the deadline for filing an appeal — most plans allow 180 days for internal appeals. If the denial reason is a coding error, your provider's billing department may be able to correct and resubmit the claim without a formal appeal.

Step 2: Gather Documentation

Collect your medical records, doctor's notes, the original claim, the denial letter, your plan's Summary of Benefits and Coverage, and any clinical guidelines that support the medical necessity of the service. If the denial is based on medical necessity, ask your doctor to write a letter explaining why the service was required.

Step 3: File an Internal Appeal

Submit a written appeal to your insurance company. Include: your name, policy number, and claim number; a clear statement that you are appealing the denial; the specific reason you believe the denial is wrong; supporting documentation; and your doctor's letter of medical necessity if applicable. Send the appeal by certified mail with return receipt requested, or through the insurer's online portal if available.

Step 4: External Review

If the internal appeal is denied, you have the right to an external review by an independent third party. Under the ACA, all marketplace and employer plans must offer external review. The external reviewer's decision is binding on the insurance company. File the external review request within 4 months of the internal appeal denial.

Expedited Appeals for Urgent Care

If the denial involves urgent or ongoing care, you can request an expedited appeal. Insurance companies must respond to expedited internal appeals within 72 hours and expedited external reviews within 72 hours. Do not wait for the standard timeline if your health is at risk.