Federal law overview
The Affordable Care Act (ACA) and the Employee Retirement Income Security Act (ERISA) require health insurers and employer plans to have internal appeals processes and to allow external review by independent organizations. The ACA specifies timeline requirements: urgent care appeals within 72 hours; standard internal appeals within 30–60 days.
Generic AI prompt template
My health insurance claim for [PROCEDURE/SERVICE] on [DATE] at [FACILITY] was denied by [INSURER NAME] on [DENIAL DATE]. The denial reason stated was: [REASON FROM EOB]. Draft a formal first-level internal appeal letter that: (1) identifies the claim by member ID [ID] and claim number [CLAIM NUMBER], (2) disputes the denial reason with reference to my policy's coverage terms, (3) requests that the insurer provide the specific plan language and clinical criteria used, (4) cites the ACA's internal appeals rights under 45 CFR § 147.136, and (5) states I will proceed to external review if the internal appeal is denied.
State-specific guides — Denied Health Insurance Claim
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- Alabama (coming soon)
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- Florida
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- Illinois
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- New York
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- Pennsylvania (coming soon)
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- South Carolina (coming soon)
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- Texas
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- Vermont (coming soon)
- Virginia (coming soon)
- Washington (coming soon)
- West Virginia (coming soon)
- Wisconsin (coming soon)
- Wyoming (coming soon)
Frequently asked questions
What is an EOB and why does it matter? +
An Explanation of Benefits (EOB) is the insurer's statement of what they paid and denied, and why. The denial reason on your EOB is the starting point for any appeal.
How many levels of appeal do I have? +
ACA-compliant plans must offer at least one level of internal appeal. If that fails, you can request an independent external review. Most states also have a state insurance commissioner complaint process.
What is external review? +
External review is an independent evaluation by an accredited organization (not your insurer). Under the ACA, insurers must comply with the external reviewer's decision. It is free to request.
Does ERISA apply to my employer plan? +
Most employer-sponsored health plans are governed by ERISA. ERISA preempts state law for these plans, so your appeal rights are governed by federal ERISA and ACA rules, not state insurance law.
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