Denied your appeal? Don’t give up. Learn about your options for internal and external appeals, regulatory complaints, and legal action to fight for the care you need.

I know how frustrating it can be to receive another denial after you’ve already fought so hard. But I want to encourage you—this isn’t the end of the road. Many patients successfully win their second or even third appeal, and I’m here to help you get through this process. At Claimable, we’ve seen firsthand how persistence can pay off, and I want to make sure you have everything you need to keep moving forward.

Let’s walk through your options and how you can strengthen your next appeal.

My appeal was denied - can I file another appeal?

Yes! You have the right to multiple levels of appeal. These usually include internal reviews by your insurance company and external reviews by independent bodies. Your denial notice will explain how to re-appeal, including options for urgent cases.

How do I strengthen my next appeal?

Here’s what we’ve learned from analyzing successful appeals:

• Activate Influencers: Journalists, healthcare providers, or even industry leaders and politicians can help put pressure on insurers.
• Executive Outreach: Appeals directed to senior executives (like the CEO or medical officers) often get faster responses.
• Employer Outreach: If you’re in a self-funded plan, your employer’s leadership (like the CEO or CFO) is ultimately responsible for the plan.
• Review Your Claim File: Look for mistakes or inconsistencies that can strengthen your appeal.
• Build Your Case: If the insurer took too long, used unqualified reviewers, or broke any rules, that can boost your chances.
• Legal Support: If your case is urgent or complex, consider reaching out to a legal expert.

What are the different levels of appeal options?

STEP 1
Internal Appeals

This is your first step—ask your insurance company to reconsider. You may need to appeal twice before moving to an external review. Be sure to submit any new evidence or arguments.

STEP 2

External Appeals

An independent board will review your case and make a decision, assigning a medical expert or review board. If they overturn the denial, your insurer must comply.

STEP 3

Regulatory Complaints

If your appeals aren’t successful, you can file a complaint with a regulatory agency, which may decide to investigate and intervene on your behalf.

STEP 4

Legal Action

If all else fails, legal action may be an option. Self-funded plans, Medicare, and federal employer plans usually go to federal court, while other plans often go to state court.

Appeal Options by Health Plan Type:

Self-Funded Employer Plans (most large insurers)

Appeal options:
‍1st: Internal Review
2nd: Internal Review*
3rd: External Review
4th: Regulator Complaint
5th: Legal Action

Relevant regulator:
‍‍Employee Benefits Security Administration (EBSA)

Fully-Insured Employer Plans

Appeal options:
‍1st: Internal Review
2nd: Internal Review*
3rd: External Review
4th: Regulator Complaint
5th: Legal Action

Relevant regulator:
State Insurance Commissioner (NAIC)

Individual / Exchange Plans

Appeal options:
‍1st: Internal Review
2nd: Internal Review*
3rd: Regulatory Complaint
Anytime: Legal Action

Relevant regulator:
State Insurance Commissioner (NAIC)

State & Local Government Employee Plans

Appeal options:
1st: Internal Review
2nd: Internal Review*
3rd: External Review
4th: Regulator Complaint
Anytime: Legal Action

Relevant regulator:
State Insurance Commissioner (NAIC)

Federal Employee Health Benefits

Appeal options:

1st: Internal Review
2nd: OPM Review
4th: MSPB Review*
5th: EEOC or OSC Complaint

Relevant regulator:
Office of Personnel Management (OPM)

Medicare & Medicare Advantage

‍Appeal options:
1st: Internal Review
2nd: External Review
3rd: OMHA/ALJ Hearing
4th: Appeal Council Review
5th: Judicial Review

Relevant regulator
Centers for Medicare & Medicaid Services (CMS)

Medicaid

Appeal options:‍

1st: Internal Review
2nd: Local Hearing*
3rd: State Hearing
4th: Office of Appeals*
5th: Legal Action

Relevant regulator:
‍State Medicaid Agency

* Optional or not always part of the process.

** See TRICARE and the Veterans Affairs for military or veteran related appeals.

Can Government Agencies Help?

Yes! Insurance plans are regulated by federal or state agencies that handle complaints and make sure insurers follow the rules. Here are some key regulators to know:

• Department of Labor (EBSA / ERISA): For self-funded employer plans
• State Departments of  Insurance: For fully-insured employer plans, state or local government employers, and individual or exchange-purchased plans
• Centers for Medicare and Medicaid Services: For Medicare and Medicare Advantage plans
• State Medicaid Agencies: For Medicaid plans
• Office of Personnel Management : For federal employer plans

Do I Need Legal Help?

Claimable doesn’t provide legal advice, but if you’ve exhausted your appeals or face an urgent issue, legal support might help. Look for attorneys who specialize in health insurance denials—especially in cases involving bad faith or breach of contract.

Resources For Financial Help

If the costs are piling up, consider these resources:

• Patient Assistance Programs: Offered by pharmaceutical companies to provide free or discounted medications.
• Non-Profit Organizations: Groups like HealthWell Foundation, PAN Foundation or Good Days help cover treatment costs.
• Discounts, Coupons or Copay Cards: Pharmaceutical companies or third parties like GoodRx offer coupons, rebates, savings cards, free trial cards or free samples.
• Government Programs: Medicare Part D Extra Help or Medicaid  offer financial aid.
• Debt Forgiveness: Programs like Undue Medical Debt or Dollar For help with medical debt relief.

Want to Learn More?

We highly recommend Marshall Allen’s book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win, for more tips on navigating the healthcare system.

‍