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Appeals

If you are recovering from an illness or injury, require surgery or medication, being denied health benefits can be stressful and frustrating. Health plans are contractually obligated to provide coverage for your healthcare, yet millions of healthcare claims are denied every year. The appeals process is fundamental to protecting individuals’ health care rights and ensuring that patients and plan participants receive the healthcare they need and deserve. At Green Health Law, we are passionate about standing up for individuals who were unfairly denied health benefits. For more information about how we can help you secure benefits, consider connecting with our team today. 

Can You Appeal a Denied Health Insurance Claim?

If your health insurance company refuses to provide coverage or withholds benefits, you have the right to appeal the decision. When you submit an appeal for a denied claim, you are requesting to have the decision reviewed and reconsidered and the benefits approved. While the appeal process can seem daunting, it is in a patient’s interests to appeal a denied claim that you and your healthcare team deem necessary for your care and quality of life. 

Appeals Facts & Statistics

Federal data from the Centers for Medicare & Medicaid Services (CMS) indicates that health insurers denied over 48 million claims in 2021, but less than 0.2% of those denials were appealed. This translates to a mere 96,000 appeals – a staggering statistic when you consider that over 60% of appeals were successful in California (Department of Managed Health Care, 2020). With the odds seemingly in the plan participant’s favor, why are so few appeals filed each year? 

From listening to current and prospective clients’ stories, we understand that individuals often choose not to appeal their denied health claim due to a deep-rooted belief that fighting back against insurance companies is a hopeless endeavor. This makes sense, as health claims administrators can stall and delay appeals through mountains of paperwork, administrative loopholes, and a wealth of resources. Moreover, these companies often have large legal teams to fight their battles and to the average person, this is understandably intimidating. 

These beliefs are rooted in fact, making the appeals process appear even more bleak. In 2017, the California Department of Managed Health fined Anthem Blue Cross $5 million for perpetuating systematic violations in the claims grievance process. This case is not an isolated incident, and frustrated patients and plan participants around the country struggle with attempting to resolve issues with health coverage and claim denials. 

Navigating the ERISA Appeals Process with Green Health Law

At Green Health Law, we are here to demystify the appeals process and ensure that patients and plan participants understand and feel empowered to exercise their rights to health benefits. The ERISA appeals process can be complicated, and many people are unsure of their options and next steps. 

What Is the Internal Appeals Process?

When you file an internal appeal, you are requesting that the claims administrator or health plan completes a full and fair review of the initial decision and approve the requested benefits. Under ERISA, plan participants have 180 days (6 months) from the date they received their denial, to submit an appeal. If the situation is urgent, your claims administrator or health plan is legally obligated to expedite the appeals process within 72 hours. However, the claims administrator may disagree with the urgency of the health condition and decline to issue an appeals decision that quickly.  

To submit an internal appeal, you must complete all the paperwork required by the claims administrator or health plan and provide any relevant information that you want reviewed. This may include treatment or medical records, or a letter from your doctor, for instance.

If your initial appeal is denied, your plan may provide for a second level appeal which could be due in as soon as 60 days from the first level appeal denial. If your insurer denies the claim after the internal appeals process is completed, you may then pursue an external review. 

What Is the External Review Process?

State departments of insurance and federal law provide for external review processes in addition to the health plan’s internal appeal process. Under the Affordable Care Act, a federal law, the external review process consists of two steps. First, you must submit a written request for an external review within four months of receiving notice that your claim was denied. Then, an independent third party will review the decision and determine whether or not you are entitled to coverage. Your health plan is legally required to accept the external review decision. 

There are a few different types of claim denials that can be externally reviewed, including: 

  • A claim that involves a medical judgment, wherein you and your plan disagree about the medical necessity of a healthcare request.
  • Claims involving experimental or investigational treatment.
  • Health coverage cancellations that stem from the health plan refusing to provide health coverage for a plan participant or dependent.

 

Some states have a review process that adheres to the protections established in the Uniform Health Carrier External Review Model Act. For example, California’s Independent Medical Review Program was established to reconsider denied health care claims in the state. CMS maintains a comprehensive list of state external review processes on their website. 

How Can Green Health Law Help with the Appeals Process?

At Green Health Law, we guide patients and plan participants through the appeals process and advocate for their interests at every step, ensuring that they successfully overturn their denial and secure coverage for their healthcare and prepare the appeal record for the possibility of litigation, if necessary. Specifically, we can help with the following matters: 

  • Reviewing the terms of your health plan for the procedures necessary to submit your appeal.
  • Filing an internal appeal which provides carefully tailored reasons for the health plan to overturn its denial and approve benefits.
  • Recommending necessary medical evidence to support your appeal.


When you work with our team of experienced attorneys, you can expect to be heard and treated as a person rather than a case number. You can expect understanding, passionate advocacy, and transparency through each phase of the appeal process and professional integrity in every facet of our work. Above all, you can rest assured that our team will fight for your rights to successfully resolve your denied claim. 

Contact Our Team

Successfully appealing an unfairly denied claim for health benefits requires careful planning and an effective legal strategy. As the law firm of choice among patients and plan participants across the nation, Green Health Law is here to help. With over two decades of experience navigating the appeals process, we understand the tactics that insurers use to deny coverage and how to successfully overturn their denial. To get started building your case, consider contacting our team of experienced attorneys today.