How to appeal an insurance decision
Most appeals go through the same ladder — here's how to climb it.
Already gathered your documents? This guide covers the appeal process itself — the levels of review, and how to write an appeal letter that actually gets read.
Show me the appeal levels ↓The appeal ladder
Each level gives the decision a fresh, generally more independent look.
Reviewed by your insurer
A different reviewer than the original decision generally re-examines your claim with any new information you provide.
Some plans offer a second review
Not every plan has this step — check your denial letter or plan documents to see if it applies to you.
Reviewed by an independent third party
Generally available once internal appeals are exhausted — a reviewer outside your insurer makes the final call.
Legal options
Most appeals resolve before this point. Legal consultation is generally reserved for high-value or complex disputes.
Standard vs. expedited
If waiting could seriously harm your health, ask specifically for expedited or urgent review — it generally moves much faster than the standard timeline at every level.
Anatomy of a strong appeal letter
- Identifying informationYour name, member ID, claim number, and the date of the denial you're appealing.
- A clear statement of what you're appealingName the specific decision and the outcome you're requesting.
- Your case for medical necessityExplain, in plain terms, why this service was appropriate for your situation.
- Supporting evidenceAttach your provider's letter of medical necessity, relevant records, and any clinical guidelines that support your case.
- A direct requestState plainly what you want: approval of the original claim, reimbursement, or a specific corrected outcome.
Common success factors
A provider's letter of medical necessity
Often one of the single most persuasive pieces of an appeal.
Correcting factual errors
If the denial is based on incorrect information, pointing this out clearly can resolve things quickly.
Citing your specific plan language
Quoting the relevant section of your plan document strengthens your argument.
Staying organized and on time
Clear, complete, on-deadline submissions are easier to process — and to win.
In Canada? The process depends on which plan denied you.
Jump to the Canadian guide ↓Two different appeal paths
The letter-writing principles above still apply either way — the process and who reviews it differs.
Private or workplace plan
Generally follows a similar internal-review, then independent-review structure to the U.S. steps above — contact your plan administrator or insurer for their specific process.
Provincial program
Appeals for a provincial coverage decision typically go through that province or territory's own appeal board or process — contact your provincial health ministry for the specific steps where you live.
What are you trying to do?
Common questions about appeals
How long does the whole appeal process take?
It varies widely by level and urgency — standard internal appeals often take a few weeks; external review timing depends on the reviewing body. Expedited review is typically much faster.
Do I have to go through every level in order?
Generally yes — most plans require exhausting internal appeals before external review becomes available, though exceptions can exist for urgent situations.
What if my appeal is denied at every level?
At that point, your options typically narrow to legal consultation or accepting the outcome — worth discussing with a professional for high-value or complex situations.
Can I submit new evidence at each level?
Generally yes — each level is a chance to strengthen your case with new documentation, not just repeat the same appeal.
Ready to write your appeal?
The Appeal Builder walks you through it step by step, using what you've learned here.