Insurance appeals — fighting denials across all types of coverage
This article is for educational purposes only and does not constitute medical, legal, or financial advice. Every family situation is different, and you should consult with appropriate professionals about your specific circumstances.
Understanding the Basics
The denial letter arrives, and your parent thinks they've hit a dead end. The insurance company said no, and they assume that means their claim is finished. This misconception costs families thousands of dollars every year. The truth is that a denial is not the end of the process—it's actually the beginning of it. Insurance companies deny claims regularly, sometimes for legitimate reasons and sometimes because of errors, misunderstandings, or processing mistakes. Your parent has the right to push back on those denials, and they have multiple opportunities to do so.
An insurance appeal is your formal request asking the insurance company to reconsider their decision. You're not asking them nicely or hoping they'll change their mind. You're using a specific process with specific rules, timelines, and requirements. When you file an appeal, you're essentially saying that you believe the insurance company made an error or didn't have all the information they needed to make a fair decision. Sometimes appeals are successful because there actually was an error. Sometimes they work because you're providing information or context that the insurance company didn't have the first time. And sometimes they don't work, but you still go through the process because not appealing guarantees you lose.
The type of coverage your parent has doesn't really matter when it comes to appeals. Medicare, private insurance, supplemental plans, Medicaid—they all have appeal processes. The specific rules vary by type of coverage and by state, but the basic concept is the same. You send a letter to the insurance company explaining why you think they made a mistake, you include supporting documentation, and you wait to hear back. If that appeal is denied, you usually have the right to appeal again at a higher level, sometimes multiple times.
Here's what matters most: most people don't appeal. They get a denial, feel discouraged, and move on. This means the insurance companies know that most denials will stick simply because people won't fight them. It also means that when someone does appeal, they're often successful, especially on the first appeal. The insurance company might reconsider their decision when presented with more information, or they might realize that the person filing the appeal is serious and knows they have rights.
The common reasons for insurance denials are these: the insurance company says the service wasn't medically necessary, it wasn't covered under your parent's plan, it wasn't pre-authorized when it should have been, the provider is out of network, the claim was submitted incorrectly, or your parent exceeded some kind of coverage limit. Some of these reasons are legitimate and might not be worth appealing. If your parent's plan genuinely doesn't cover a service, appealing won't change that unless you're appealing because the claim was coded wrong. But many denials happen because of miscommunication, clerical errors, or the insurance company making a judgment call about medical necessity that a doctor might dispute.
Understanding why the denial happened is your first step. The denial letter will tell you the reason, though sometimes the language is vague or uses industry terminology. You're looking for phrases like "not medically necessary," "not covered under your plan," "out of network," "exceeds limitation," or "requires pre-authorization." Once you understand the stated reason, you can figure out whether you have a real argument against it.
Your Parent's Specific Situation
Before you file an appeal, you need to gather information about your parent's specific situation. Start with the denial letter itself. Read it carefully and see if you can understand why the insurance company said no. If the reason isn't clear, or if you believe the reason is wrong, that's your starting point for the appeal.
Next, you need to understand your parent's actual coverage. What does their plan say about the service that was denied? If your parent has a paper copy of their plan documents, look for the section about the denied service. If they don't have the documents, contact the insurance company and ask them to send you a copy of your parent's plan or direct you to the specific language about the denied service. You're looking for language that either covers the service or doesn't. If your parent's plan covers the service, the denial should never have happened. If the plan has confusing language about whether the service is covered, that ambiguity might be your argument.
You'll also need documentation from your parent's healthcare provider. Call the doctor's office or the hospital and ask them to send you documentation explaining why they recommended the service for your parent. If it was a medication or treatment, ask them to explain why they believed it was medically necessary. If it was a diagnostic test, ask them to explain what medical problem it was meant to investigate. You're collecting evidence that the service was appropriate for your parent's situation, not just a procedure that the insurance company didn't want to pay for.
Ask your parent what they remember about the service and why it was recommended. Did the healthcare provider mention that it might not be covered? Did anyone talk to them about costs before the service was provided? Did your parent sign any paperwork? Sometimes your parent remembers details that are important to the appeal,maybe the doctor said the service was medically necessary to diagnose or treat a condition, or maybe your parent was told it was covered. Those details matter.
You should also check whether your parent received a pre-authorization request before the service. Some services require the insurance company to approve them before they happen. If the healthcare provider was supposed to request pre-authorization and didn't, that might be why the claim was denied. If the provider did request it but was denied, that's different information that you might need for the appeal.
Finally, determine what your parent would need to do to get the service covered. Sometimes the answer is simple: they need to change providers to an in-network provider, or they need to wait until next year when a new deductible applies. Sometimes it's more complex: they need to get a different doctor's opinion or try a different treatment first. Understanding what your parent would need to do helps you decide whether appealing is worth the effort.
Taking Next Steps
Once you've gathered information, you need to decide whether to appeal. Not every denial is worth appealing. If your parent's plan genuinely doesn't cover the service, appealing is probably a waste of time unless you believe the claim was coded incorrectly and should have been covered under a different service code. But if the denial seems like an error, if the insurance company applied the rules incorrectly, or if there's a legitimate question about whether the service was medically necessary, then appealing makes sense.
Most insurance companies have an appeal deadline. It's usually 30 to 60 days from when your parent received the denial letter, though some plans allow longer. You need to appeal within that window or you lose the right to appeal. Write down the deadline on your calendar or somewhere you won't forget it. If you think you might appeal, don't wait until the last minute to gather information. Start as soon as you receive the denial.
Your appeal should be in writing, even if the insurance company tells you that you can call. Put your argument in writing so there's documentation of what you said and when you said it. Your letter should include your parent's name, policy number, the date of service, the specific claim or service you're appealing, the reason you believe the denial was wrong, and any documentation that supports your position. Keep it clear and concise. The person reading your appeal is probably processing hundreds of appeals, so don't bury important information in long paragraphs.
Your supporting documentation is critical. Include a copy of the denial letter, your parent's plan documents (or the relevant section of them), the healthcare provider's statement about medical necessity, any test results or other clinical information that supports the appeal, and your own explanation of why you think the denial was wrong. Make copies of everything and keep the originals for your records.
Send your appeal to the address on the denial letter. Some insurance companies prefer email, some prefer mail. Use the method that provides tracking so you can confirm that your appeal was received. Keep the confirmation for your records.
Once you've sent your appeal, there's a waiting period. This can range from a few days to a few weeks depending on the type of insurance and the complexity of the appeal. During this time, the insurance company will review your appeal and your documentation. They might contact your parent's healthcare provider to ask questions. They might request additional information from you.
If your first appeal is denied, you usually have the right to a second-level appeal. Some insurance plans call this an "appeal of appeal" or an "external review." The rules differ by type of insurance and by state, but the general idea is that you get another chance to present your case to someone higher up in the insurance company. Second-level appeals take longer and are more formal, sometimes involving a hearing or a written review by a specific person. But they have a higher success rate than first appeals, partly because your documentation is more polished and partly because you're talking to someone with more authority.
If you've exhausted the insurance company's internal appeals process and you still believe they made an error, you might have access to an external appeal. This means an independent person or organization outside the insurance company will review your case and make a decision. Medicare appeals, for example, can go all the way to the federal level if you want to pursue them. Other types of insurance vary by state. Check your plan documents or contact your state insurance commissioner's office to find out what options are available for your parent's specific situation.
The appeal process requires patience and persistence. But it often works. Even when it doesn't result in the denial being overturned, going through the process gives you a complete understanding of why the insurance company said no, which helps you figure out your next steps. Sometimes the answer is to pay out of pocket, sometimes it's to try a different healthcare provider or treatment, and sometimes it's to accept the denial and move forward. What matters is that you made an informed decision rather than accepting the no without questioning it.
How To Help Your Elders is an educational resource. We do not provide medical, legal, or financial advice. The information in this article is general in nature and may not apply to your specific situation. If you are concerned about a loved one's healthcare coverage or insurance claims, consult with their healthcare provider, insurance company, or contact your local Area Agency on Aging for guidance and support.