When insurers deny you the care and coverage you deserve, it’s time to stand up, know your rights, and challenge violations head-on. This beginner's guide to patient appeals will cover ten essential patient rights everyone should know.
Imagine this.
You’ve been denied health insurance coverage for a treatment your doctor says you desperately need—not by a person, but by artificial intelligence (AI). That’s the reality more patients are facing as insurers increasingly rely on AI auto-denials, often without proper review. Mistakes are skyrocketing, and insurers aren’t always following the rules.
But here's the silver lining: you have the power to push back.
The Affordable Care Act (ACA) grants patients strong appeal rights that go beyond the protections health providers can request on their behalf.
Beyond well known protections for pre-existing conditions, coverage limits and preventative health services, the ACA also protects Americans from unjust denials. These rights are further supported by similar laws in the Employee Retirement Income Security Act (ERISA), Health and Human Services (HHS) and in all 50 states.
When insurers deny you the care and coverage you deserve, it’s time to know your rights and challenge them head-on. Every Claimable appeal is tailored to do just that, which is why patients using Claimable are successful 85% of the time—1.7 times higher than the industry average.
Not sure what your rights are?
Start Here: 10 Essential Appeal Rights to Fight Health Insurance Denials
Right to Multiple Appeals
You are entitled to multiple levels of patient appeals, including internal appeals, independent external reviews, judicial review and regulatory complaints. By contrast, providers are only allowed internal appeals or payment disputes.
The takeaway:
Insurance companies mess up or don't follow the rules—a lot. That's why appeals exist! Think your denial is bogus? File a patient appeal with a supporting statement from your doctor. And if your first attempt doesn't cut it, keep escalating for more chances to win.
Read the fine print:
Right to a Qualified (Human) Reviewer
Your appeal must be reviewed by a healthcare professional—not an algorithm—with the right clinical expertise in treating your condition. And no, they're not supposed to be incentivized to deny your claim.
The takeaway:
Always ask for the National Provider Identifier (NPI) to confirm your reviewer’s qualifications. And if there’s evidence the insurer retaliates against fair reviewers or rewards those who deny claims, that could be a powerful argument for your case.
Read the fine print:
Right to a Full and Fair Review
Insurance companies must conduct a comprehensive review of all the information submitted with an appeal. This includes giving you the opportunity to present new evidence and ensures your access to your claim file.
The takeaway:
Use this to your advantage! If you've got new evidence that supports you case, use it. And don't forget to ask for your case file—it can contain valuable insights that back your case and you're entitled to see everything they used to make their decision.
Read the fine print:
Right to Clear and Timely Notification
Insurers must give a written explanation for any denial, with appeal instructions, within these timeframes: 72 hours for urgent needs or formulary exceptions,15 days for prior authorizations, and 30 days for standard reviews.
The takeaway:
Demand your denial notice in writing—it’s your roadmap for fighting back. If they stall, report them to your regulator. The notice, often called a Notice of Adverse Benefit Determination or Explanation of Benefits (EOB), reveals why you were denied and outlines your appeal rights.
Read the fine print:
Right to Formulary and Tier Exceptions
You can request and gain access to clinically appropriate medications not otherwise covered by your plan. If approved, the plan must cover the full prescription duration, waive dosing restrictions, or lower costs.
The takeaway:
Is your medication "not covered"? Ask for a formulary exception! It's fast and if they deny it, you can escalate. If the medication is necessary and alternatives won’t work or could harm you, this lets you request full coverage, override limits, or get non-preferred drugs at preferred prices. Tip: doctor's statement is sometimes required.
Read the fine print:
Right to Adequate Network
Insurance companies must provide access to a sufficient number of providers within a reasonable distance and time frame, guaranteeing patients timely access to necessary medical care without excessive travel or delays. (NCSL)
The takeaway:
Don’t settle for long waits or drives—your plan must provide timely, nearby care that meets your needs. If the network falls short or if switching providers would cause a risky gap in care, you may qualify for in-network coverage elsewhere.
Read the fine print:
Right to Safe & Suitable Site of Care
Patients have the right to receive care in a setting that is safe, effective, and appropriate for their medical needs. This includes protection from being forced into unsafe, discriminatory, or inaccessible sites of care.
The takeaway:
Your care, your choice! Plans shouldn’t force you away from your trusted team or push you to facilities with higher costs, longer commutes or unsafe care. Fight to stay with the providers who truly understand your needs—it's worth it.
Read the fine print:
Right to Safe Step Therapy
In 38 states, laws protect patients from being forced into potentially harmful or ineffective treatments through ‘fail-first’ step therapy protocols. These protections allow patients to request exceptions to step therapy rules when the patient is stable on their current treatment or the health plan’s preferred drug is unsafe.
The takeaway:
Take control of your treatment! Step therapy protections empower you to request exceptions if a preferred drug isn’t right or if you're stable on your current care. Know your rights—fight back to stay on the care that keeps you healthy.
Read the fine print:
Right to Evidence-Based Decisions
Insurers must determine the medical necessity of your treatment based on credible scientific evidence and standards accepted by the medical community. These decisions should never be arbitrary or purely cost-driven.
The takeaway:
If your insurer tries to override your doctor’s orders or ignore accepted standards, push back. Request your Summary Plan Description (SPD) to confirm if they’re following their own rules and challenge any outdated or unsubstantiated policy.
The fine print:
Right to Have All Copays Count
Patients are entitled to have all payments—including those made through third party assistance programs—count toward their deductibles and out-of-pocket maximums.
The takeaway:
Although a federal court struck down copay accumulator programs in September 2023 for treatments without generic equivalents, some insurers still try to enforce them, betting that patients won’t know their rights or push back.
The fine print:
You can find specific language about your health insurance appeal rights within the ACA, from HHS and from the Department of Labor (ERISA).
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