Insurance Rights
A denial is an opening position. Federal law gives you a structured way to challenge it.
You are entitled to a written explanation of any denial, including the specific reason and the plan provision it relies on.
You have the right to an internal appeal, and if it is denied, an independent external review by a reviewer who does not work for your insurer.
The No Surprises Act protects you from most surprise bills for emergency care and for out-of-network care delivered at an in-network facility.
You can request the clinical criteria the insurer used, and you can ask for a peer-to-peer review between your doctor and the plan's medical director.
Why it matters
A large share of appealed denials are overturned. Most denials are never appealed — which is exactly why insurers can afford to issue them.
What to do
- Read the denial letter for the deadline. It is usually 180 days for an internal appeal.
- Ask your clinician's office for a letter of medical necessity referencing the plan's own criteria.
- Escalate to your state insurance commissioner when the plan is state-regulated, or to the Department of Labor for most employer self-funded plans.
Educational purposes only
Phoenix Health Compass does not provide legal advice or medical advice. This content summarizes publicly available government and nonprofit resources and is cited throughout. Always confirm requirements, deadlines, and forms with the official agency.
Last reviewed by the Phoenix Health Compass editorial team.