🩺 Medical care & bills

Health-insurance denial and prior-auth appeal writer

Writes a health-insurance denial or prior-authorization appeal, routes it to the right review, and keeps track of each deadline.

Life event: claim or prior-authorization denial for a doctor-ordered test, drug, surgery, or course of treatment

Problem

HealthCare.gov qualified health plans denied 19% of in-network claims and 37% of out-of-network claims in 2024 (KFF, Mar 24, 2026: ~85 million in-network denials of 451 million claims). Consumers appealed fewer than 1%; insurers upheld 66% of internal appeals (~34% overturned). North Carolina’s Smart NC program overturned 153 of 282 external reviews through November 2025 — 53% (NBC News, Dec 10, 2025). Pennsylvania’s Independent External Review overturned 50.1% in its first year (259 reversals; PID, Jan 8, 2025) and about 48% since 2024 (655 of 1,353; PID, Apr 3, 2026).

Intake

Denial letter / adverse benefit determination (ABD) / EOB: reason, diagnosis and CPT/HCPCS, guideline citation, appeal address, clocks, urgent-care and external-review rights.
Card (front/back), member ID, group number, TPA name; SBC, EOC/certificate; for employer plans, SPD and plan document.
Prior-authorization letter; billed codes vs authorized codes.
Treating clinician records, failed alternatives, letter of medical necessity.
Phone log; plan type (Marketplace / fully insured group / self-funded ERISA / governmental / Medicare Advantage / Medicaid); authorized-representative form if someone else will file.

Playbook

Stabilize care the same day if delay is dangerous. Treating clinician files expedited internal appeal and expedited external review together, attesting that delay would seriously jeopardize life, health, or maximum function, or cause unmanaged severe pain (29 CFR 2560.503-1(m)(1); 45 CFR 147.136(b)(2)(ii)(B) — plan must defer to the attending on urgency). Plan decision: 72 hours (CFR). Healthcare.gov’s “4 business days” is consumer copy; use the regulation.
Identify the plan type in 10 minutes. Marketplace / individual fully insured → state DOI if NAIC-parallel, else HHS FERP. Fully insured group → state process. Self-funded private ERISA → federal IRO; DOL EBSA is the cop. Self-insured city/school → FERP. Medicare Advantage is 42 CFR Part 422 Subpart M (60-day reconsideration, then automatic IRE) — do not mix with ACA clocks. Medicaid MCO: 60-day plan appeal, then fair hearing.
Calendar from receipt, not the letter date. Internal: ≥180 days from receipt (2560.503-1(h)(3)(i)). Plan decides: urgent 72 hours; pre-service 30 days (15 each if two levels); post-service 60 days (30 each). External: ≥ four months after receipt of the final internal ABD (45 CFR 147.136). No corresponding date (Oct 30 → no Feb 30) → first of the fifth month (March 1). Pennsylvania: 15 business days supporting info after IRO assignment; IRO 45 days. Do not burn external on a voluntary second internal level.
Demand the claim file, guideline, and Dx/CPT meanings in writing the same day, free. 2560.503-1(h)(2)(iii), (g). New evidence or a new rationale must be disclosed in advance; the clock tolls if too late to respond (147.136(b)(2)(ii)).
Peer-to-peer is not the appeal. Use it immediately on a PA denial (often 24–72 hours). Confirm in writing. The 180-day written-appeal clock does not toll unless the plan agrees in writing.
One thesis sentence, then exhibits. “This [service] is covered and medically necessary under [plan / NCCN 2A / FDA label] because [one sentence].” Attach LMN, records, the plan’s own guideline, society guidelines, FDA/compendia for off-label cancer. 45 CFR 147.136 Example 1: visit-limit denials that secretly turn on medical necessity are external-review eligible.
File the written internal appeal at the ABD address. Individual market: one internal level. Group: at most two mandatory. Reviewer cannot be the initial denier or their subordinate. Missed 72h / 15d / 30d / 60d clocks → deemed exhaustion (narrow de minimis exception at 147.136(b)(2)(ii)(F)).
File external review the day the internal is upheld. Read the bottom of the final ABD. HHS FERP (AL, FL, GA, TX, WI + most territories; CMS table modified Aug 14, 2026): https://maximusferp.my.site.com/FERP/s/ , 1-888-866-6205, ferp@maximus.com. $0 fee. IRO de novo: 45 days (72 hours expedited), binding. Some state processes may charge ≤$25 (refundable if reversed; $75/year cap) if they authorized a fee as of Nov 18, 2015.
Route CA / NY / TX by the letter. CA Knox-Keene HMO → DMHC IMR. CA fully insured PPO → CDI. NY DFS: patients 4 months; providers on their own behalf 60 days. TX fully insured → TDI IRO form LHL009 sent to the plan/URA (CMS still lists TX in the FERP column — use the denial letter).
Parallel levers. DOI complaint (fully insured). EBSA Benefits Advisor: https://www.askebsa.dol.gov/ or 1-866-444-3272. MHPAEA if MH/SUD limits are tighter than med/surg (2013 rule + CAA 2021 analysis still live). Employer is the ERISA fiduciary. NSA IDR is provider–plan payment, not a member coverage path.
IRO reverse: authorize and pay without delay; stall → DOI/EBSA / ERISA § 502(a). IRO uphold: § 502(a); MA continues to IRE/ALJ (CY 2026 AIC ≥ $200 ALJ / ≥ $1,960 federal court). Dispute collections in writing while the appeal is open.

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