Action Plan: Health insurance plan denied a claim

Action Plan

Talk to your Human Resources department if you get health insurance through your employer. Ask if your health plan is “self-funded” or “fully insured.”

Some employers use “self-funded” health plans. In these plans, the employer takes on the risk of providing coverage. They might use a health insurance company to administer the plan.

If you have a “self-funded” plan, ask your employer or the health insurance company administering the plan to reconsider their denial, or make an exception.

Employers can make exceptions in accordance with their plan rules.

File an internal appeal with your employer or health insurance company.

You can file an internal appeal whether your insurance is provided by your employer or you bought it on your own.

Ask the company to reconsider its decision. They must tell you why they’ve denied your request to pay. 

Learn how to file an internal appeal on HealthCare.gov

If you disagree with the results of the internal appeal, file an external review.

Take your appeal to an independent third party for review. The review may cost up to $25. 

Your health insurance company must accept the reviewer’s decision. 

Note: You may need to go through another round of internal appeals before you begin an external review. And not all types of appeals are eligible.

Learn more about the external review process on HealthCare.gov

Get help from outside resources.

Here are more resources to help you resolve your issue:

Consumer Assistance Programs

Consumer Assistance Programs may be able to give you advice for your specific case in the state you got care.

Find a Consumer Assistance Program in your state on CMS.gov

Patient advocates

Patient advocates can handle medical billing issues on your behalf.

Find out how patient advocates can help you

Friends and family

Consider asking a loved one for help. They can advocate on your behalf if you're feeling sick or overwhelmed.