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Here’s the situation: You and your healthcare team have decided that a treatment or medication is right for you, but your insurance company issues a denial. When the insurance company refuses to cover your medical care or a prescription drug, this is called a denial of coverage.
Your coverage can be denied before or after you receive your treatment or medication. When this happens, you can submit an appeal to the insurance company. This is called an internal appeal. If this is denied, you have an additional option: submitting an external appeal to an independent review organization.
This page will walk you through the appeals process so you can feel empowered each step of the way.
Insurance companies are required to tell you why they’ve denied your claim and how you can appeal their decisions. Sometimes, a denial may be because of an error in how the claim was submitted. In other cases, the treatment or medication requires preauthorization or is not covered under your plan.
Contact your insurance company for details on its appeals process or consult your denial letter for instructions on how to file an appeal. Submit your appeal and wait about 30 days for a response (times may vary by insurer). Note: Some plans may have multiple levels of internal appeals. This may include a peer review, during which the plan will contact a doctor who is not involved in your care to review the claim.
When your health insurance company denies your internal appeal, the next step may be to request an external appeal to an independent review organization. There must be 2 appeals denied prior to beginning the external appeal process. This process is available for individual and employer-sponsored health insurance plans.
The external appeals process varies by state. Please click on your state in the map below or select from the drop-down menu to get the information that is applicable to you.
This information is intended for U.S. residents only and is provided purely for educational purposes. Health, regulatory, insurance, or financial-related information provided here is not comprehensive and is not intended to provide individual guidance or replace discussions with a healthcare provider, attorney, or other experts. All decisions must be made with your advisers considering your unique situation.
Your healthcare provider team can support you throughout the appeals process—they may even file the appeal on your behalf
Request a letter of medical necessity from your healthcare provider, which should include the reasons why it is medically necessary for you to get the care they have provided/recommended. Please click here to download a sample letter of medical necessity for reference
Include all the information requested by your insurance company (eg, name, identification number, name of provider, dates of service, claim reference number, etc)
Complete forms exactly as requested to avoid rejections due to small errors
Get a copy of your records from your insurance company and request any decisions it makes in writing
Create a digital or hard copy folder with any documents you send to or receive from your insurance company
When contacting the insurer, note the dates and methods of contact, the names of people you talk to, and summaries of conversations
Provide any additional resources, including a patient narrative letter. Please click here for a sample patient narrative letter for reference
Be mindful of deadlines (see chart below)
Swipe to view full chart
| Type of appeal | Reason for appealing | When to submit appeal | Timeline for decision from insurance company |
|---|---|---|---|
| Preauthorization appeal | Denial preventing you from receiving care | Within 180 days | Within 30 days of initial appeal |
| Posttreatment appeal | Denial is for payment of care you received (meaning that you are responsible for 100% of charges) | Within 180 days | Within 60 days of appeal |
| Urgent care (or expedited appeal) | Delay in treatment would jeopardize your life/overall health, affect your ability to regain maximum function, or subject you to severe and intolerable pain | Within 180 days (if urgent, you can ask for external review at the same time as internal review) | Within 72 hours of receiving appeal |
You may have to go through several levels of appeals to get care approved
Stay patient and remember to tap into support from your healthcare provider team
Patients should always ask their doctors for medical advice about adverse events. You are encouraged to report adverse events related to Pfizer products by calling 1-800-438-1985 (US only). If you prefer, you may contact the US Food and Drug Administration (FDA) directly. Visit http://www.fda.gov/MedWatch or call 1-800-FDA-1088.
The health information in this site is provided for educational purposes only and is not intended to replace discussions with a healthcare provider. All decisions regarding patient care must be made with a healthcare provider, considering the unique characteristics of the patient.
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