If your health insurance company doesn’t pay for a specific health care provider or service, you have the right to appeal the decision and have it reviewed by an independent third party.
Your insurance company must first notify you in writing within a set amount of time (based on the type of claim you filed) to explain why they denied coverage. They also must let you know how you can appeal their decisions.
Note: If you want to appeal a Marketplace decision about eligibility or tax credits, see Can I appeal a Marketplace 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 appeal: 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.
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