For Consumers

How to appeal a health insurance denial

You can win an appeal, but it takes some work. First, read the denial letter. Why was coverage denied? What's the appeals process and timeline?

If it's a billing or claims-processing error, call your medical provider's billing office and ask them to clear things up with the insurer. If a bill is due during your appeal process, consider these suggestions.

If it isn't a billing or claims-processing error, you'll need to appeal to overturn it. Here are some suggestions that might help.

For continued care in an urgent situation

A health plan must provide continued coverage pending the outcome of an appeal. It can't reduce or stop benefits for an ongoing course of treatment without providing you advance notice and an opportunity for review (RCW 48.43.535(7) (leg.wa.gov).

Note: if you lose the appeal, you may be responsible for those medical costs.

Tips for filing your appeal

You may want to search health insurance appeal outcomes

If your health plan upholds a claim denial after you completed its appeals process, you can request an external review of your appeal using an Independent Review Organization (IRO). An IRO isn’t affiliated with your insurance company and doesn’t have a financial interest in the outcome of your case.

Our IRO search tool allows you to search IRO decisions, where you can modify your search based on a number of factors, including cases involving your insurance company, diagnosis, treatment, outcome or reason for the appeal.

You may want to also file a complaint

Whether or not you file an appeal, you may also want to file a complaint with our office. The appeals and complaint processes are different, and can take place simultaneously without affecting each other. If in doubt, you may want to try both avenues to resolve your issue.