Claimable Blog

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.

‍

Claimable's CEO, Warris Bokhari, MD, shares Claimable's mission to challenge denials in an open letter to celebrate our launch.

Providing healthcare to a population as diverse as ours is no easy task. It requires balancing evidence-based science, cost-effectiveness, and scalable delivery. Ultimately, it’s about empowering doctors to do what’s right for their patients.

However, as a doctor, former healthcare executive, and someone living with a chronic condition, I’ve seen firsthand that the US healthcare system is often a business first and focused on patient care second.

It’s also infested by middlemen businesses that drive up costs and block access. After decades of working within and examining the healthcare system, I became determined to understand where things went wrong—and more importantly, how to make them right.

The more I dug in, one thing became abundantly clear: better patient care often doesn’t align with bigger business incentives. Too often, short-term profits are prioritized over patient lives, provider autonomy or even long-term healthcare savings. This imbalance deeply troubled me.

As someone who's spent years developing patient care models, I’ve seen that getting results takes time—lots of it. You come up with a hypothesis, test it, and if it works, hope someone turns it into a product.  On the flip side, success in the U.S. healthcare system seems to be defined as managing and defending payments rather than helping patients. For example, in the last decade, we’ve seen telehealth companies come and go, while risk adjustment companies in the medicare advantage space have raised vast amounts of money without producing better patient outcomes.

After almost a decade working in big corporations, I realized that the industry wasn’t just failing patients, it was actually working against them, making it hard for them to get the care they deserved. One of the biggest barriers? Denials. I was shocked by the numbers: 850 million claims denied each year? 1 in 5 people impacted? This seems unbelievable, but it’s real.

In the insurance world, denials are often blamed on "fraud, waste, and abuse." But is that really the whole story? In exploring the concept for Claimable, I started talking to people facing denials and heard countless horror stories of essential care being rejected without clear explanations or alternatives.

What struck me most was this: when people do appeal, many of these denials get overturned. But here’s the problem—almost no one actually appeals.

I knew from my time inside that insurers aren’t really hearing the stories of people they deny care to. My gut told me this was the start of a hidden public health crisis.

At that point, I knew something had to change, but I couldn’t do it alone. That’s where my co-founders, Alicia and Zach, came in and Claimable came to life. I’ve always loved working with people who are smarter than me—it pushes me to think outside the box and lean into more of a creative space.

Alicia, Zach, and I were united in wanting to solve real problems, along with a sense of impatience about the pace of change in the healthcare industry. We see a (somewhat) straight line between where we are and a better world, but the path is not an easy one. We’re rowing against the tide of traditional healthcare, going up against an industry that’s comfortable making a lot of money the old way.

But we’re all driven by the same goal: to fix real problems in healthcare and help pave the way for true innovation.

We’re also bound by personal experiences that led us here. In my case, having been raised by two disabled parents and having practiced medicine in the UK where patients never got denied, I deeply understand the importance of accessible healthcare. For Zach, access to care is as critical as the care itself. Driven by his passion to eliminate healthcare barriers, he spent years at the VA improving care for veterans. And Alicia, as the child of a nurse, became relentlessly curious about reimagining healthcare experiences and finding the best way to fix them.

Ultimately, what unites us is a sense of optimism. We genuinely believe the system can be better, and we’re willing to prove it. We’re not afraid to be told we’re wrong, but we’ll keep doing the work to make sure we’re right.

In the past few months, we’ve been fortunate to work directly with patients and provider groups. We’ve gotten to know their stories and we’ve deeply felt their wins, their losses, and their tragedies. We’ll never forget the migraine sufferer who became functionally disabled after years of stability, losing their ability to work when their care was suddenly denied. And we’ll always be grateful to the practice manager who inspired us with her social advocacy campaigns and her decision to become our first customer, leading to the first of many successful appeals.

All of this keeps us moored to our mission. It sets the tone for everything we do - from the culture inside the company and empathy embedded in the experiences we build, to the quality of the data we use and our passion for seeking continual improvement. 

We’re focused on building a future where patients come first—not payment models.

Our mission is clear: ensuring everyone gets the care they need and the coverage they deserve.

Thanks for coming with us on this journey.

Warris Bokhari, MD

‍

February 11, 2024 UPDATE: We are seeing an increase in denials following the recent AAP report on PANS/PANDAS. Although the December 2024 report states, "Because they are limited by the present level of evidence on the topic, the findings are presented as a report rather than a clinical practice guideline," insurers are citing it as a guideline to justify denying previously approved care. Our team is actively collaborating with experts to refine appeal strategies in response to these challenges.

‍

Re: Selective Interpretation of PANS/PANDAS Evidence

January 31 2025

Warris Bokhari

Claimable Inc.

To the Editors:

I just finished reading the AAP's report on PANS, and while it is thorough, it raises several significant concerns that I believe warrant attention:

First, the report does not list any authors beyond the board, nor does it identify the individuals or institutions consulted as experts. This omission is unusual and raises questions about whether true expertise in managing this complex condition was adequately represented.

Second, the diagnostic pathway outlined is so intricate that it seems unlikely most insurers will provide coverage, putting families in a precarious position where they cannot exclude significant negatives and thus unable to access necessary care.

Third, while the report criticizes existing studies for being small, this critique seems misplaced. Given the relatively low incidence of PANS/PANDAS in the population, small sample sizes are to be expected in research on rare diseases. Nevertheless, I have come across numerous studies using standardized instruments that demonstrate measurable improvements in affected children.

Finally, I am concerned that the evidence review stops in 2023, excluding important recent studies like Melamed et al. (2024), which demonstrated the benefits of IVIg treatment on psychometric tests related to OCD. In addition, Melamed et al. (2021) previously published a larger open-label study showing IVIg’s effectiveness in alleviating symptoms. Given the timing of this report and the significance of these findings, it is puzzling that they were not included, particularly since position papers like this remain valid for five years.

In summary: I am deeply concerned that this position paper will be used by insurers to justify sweeping and irreversible denials of care, leaving many families unable to access treatment. The concern in the PANS/PANDAS communities among families based on this highly selective interpretation of the existing evidence.

While I recognize the limitations of small studies in this field, such limitations are common in rare disease research. The strong stance taken by the AAP could have serious implications, limiting access to the care that children with PANS/PANDAS urgently need.

Sincerely,

Dr. Warris A. Bokhari, M.B., B.S.

Submitted on January 31 2025

‍