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ACA § 2719 · State DOI

Insurance Denial Appeal Letter

Insurers deny over 17% of in-network claims — and most denials are never appealed. The Affordable Care Act gives you the right to a full internal review and, if that fails, an independent external review your insurer cannot override.

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Common denial reasons — and how to fight them

"Not medically necessary"
Cite your physician's recommendation and published clinical guidelines. Request the clinical criteria the insurer used.
"Prior authorization required"
Argue retroactive authorization for emergencies, or that the insurer waived the requirement by failing to notify in advance.
"Out-of-network provider"
If no in-network alternative was reasonably available, argue the No Surprises Act or network adequacy rules apply.
"Experimental or investigational"
Cite peer-reviewed clinical evidence and FDA approval status. Request the insurer's definition of "experimental."
"Duplicate claim"
Provide the original claim date and denial — demonstrate the prior denial was erroneous, not a duplicate submission.
"Service not covered"
Request the exact policy language excluding the service. Many exclusions are applied incorrectly or ambiguously.

Your appeal rights under federal law

ACA § 2719 (42 U.S.C. § 300gg-19) — Internal Appeal

You have 180 days from the denial to file an internal appeal. The insurer must acknowledge your appeal and issue a decision. Standard claims: decision within 60 days. Urgent/concurrent care: 72 hours. Expedited appeals must be available for time-sensitive situations.

ACA § 2719 — External Independent Review

If the internal appeal fails, you have the right to an external independent review by a neutral third party. The external reviewer's decision is binding on the insurer. This right cannot be waived by your plan documents.

ERISA (for employer-sponsored plans)

If your plan is employer-sponsored, ERISA governs the appeal process. ERISA plans must follow Department of Labor claims regulations. Failure to comply with ERISA procedures entitles you to file in federal court.

Internal vs. external review

Internal Appeal (Step 1)
→Filed directly with your insurer
→180 days from original denial
→Standard: decision within 60 days
→Urgent: decision within 72 hours
→Insurer reviews its own decision
→Free — no cost to you
External Review (Step 2)
→Filed with your state DOI or federal marketplace
→Available after internal appeal exhausted
→Independent organization reviews the claim
→Decision is binding on your insurer
→Most states: free or nominal fee
→NC: 1-855-408-1212 · FL: DFS complaint

Insurance claim denied?

Get a letter that cites ACA § 2719, challenges the denial reason directly, and invokes your right to external independent review if internal appeal fails.

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