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.

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‍What's behind our platform? Artificial intelligence is our superpower.

AI and automation have, for better or worse, become a common part of the health insurance industry. These technologies are used daily by insurers to review claims and, often unjustly, deny them.

At Claimable, we’re building AI tools that empower you - the patient. We’re leveling the playing field, leveraging technology to help you reclaim control and get the care you’re owed.

But what does that mean exactly? Let’s dive in and explore how our AI technology works, and why it gives you an appeals advantage unlike anything else. 

Who are the real-life people behind your AI? 

First, let me introduce myself. I’m Zach, Chief AI Officer. Before co-founding Claimable I spent nearly 15 years at the US Department of Veteran Affairs, serving most recently as Chief Data Scientist. I’m also a lecturer at the University of Iowa Tippie College of Business. All that to say, I’ve devoted my career to building innovative technologies that improve patient’s access to care. 

At Claimable, my team of engineers worked hand in hand with accredited doctors and insurance insiders, spending months researching, developing, and fine-tuning our AI-powered appeals platform. And our work is never done.

As an NVIDIA Inception Program member, we continue to push the boundaries of AI innovation in healthcare.  AI is evolving rapidly, as are insurance policies and regulations, and we’re constantly enhancing the experience so that you have access to the latest and greatest AI has to offer. 

How is AI Being Used to Generate My Appeal?

To start, we gather the details of your case. Don’t worry, it’s easy. We’ll ask you a few questions and have you upload relevant paperwork. From there, AI takes care of the rest. Our custom-built technology takes your specific case details and cross-references them against a huge database of published medical evidence, applicable laws, and other relevant sources. Using large language models and machine learning algorithms, we synthesize large amounts of data into a clear, legally sound argument advocating for your right to receive care. 

In addition to gathering relevant information, our AI is trained to recognize patterns in successful appeals and apply these insights to new cases, continually improving over time and allowing you to leverage the success of previous appeals in your own.

This is the incredible power of AI and how it gives you superhuman appeals powers, with just the click of a button.

Will It Be Personalized to My Situation, or a Form Letter?

Every appeal generated by Claimable is highly personalized. It assesses each case on its merits, considering individual patient details, medical history, and relevant precedents. Unlike generic form letters, each appeal is uniquely tailored to address the specific points of your denial, significantly improving the likelihood of a successful outcome.

Are Any Humans Involved In The Process, Or Is It 100% AI-generated? 

The process of creating your appeal is done exclusively by AI. Think of it like having your very own team of AI-powered researchers, writers, and editors. The researcher and wordsmith AI draft your appeal, and the editor AI makes sure everything is correct and trustworthy. This two-step process ensures that your appeal is both correct and compelling. If there are issues with an appeal, our review team can work to resolve them. 

Will It Sound Like A Robot Wrote It?

Our AI is programmed with advanced language models that produce text indistinguishable from a human professional. In other words, no robot voice here. We understand the importance of tone and language in appeals, and our AI captures them expertly. This ensures your appeal document is not only effective but also empathetic and articulate.

Will I Need to Know How to Word a Prompt?

No, you do not need to know how to word a prompt for our AI. The system is designed to be user-friendly; you simply share the necessary details of your denial, and the AI handles the rest. The Claimable experience guides you through every step of the way, no technical experience required.  

I’m Not An Appeals Expert, Am I Expected To Catch Mistakes?

We don’t expect you to be an expert. Few people, including most doctors, are! That is why Claimable includes multiple layers of checks. After the initial draft is created, other AI models, trained as reviewers, analyze the content for errors or misrepresentations, correcting them before the appeal is finalized. Learn how to review an appeal here.

How Do You Prevent Hallucinations?

A hallucination is a response generated by AI that contains false or misleading information presented as fact.

To prevent hallucinations, Claimable uses only verified data sources and cross-references information across multiple databases.

If an inconsistency is detected, the system automatically flags and revises the questionable content, ensuring reliability and accuracy.

What If I Need To Reach An Actual Human For Help? 

Once your appeal is ready, you'll have the opportunity to review it. If you spot anything that doesn’t look right, you can mark it for further examination. Our system is designed to catch and correct most issues automatically. However, if there’s a need for additional oversight, our team is prepared to step in and ensure everything is handled correctly, providing support when necessary.

Wouldn’t It Be Better If My Doctor Did This vs AI? 

While doctors are experts in medicine, they are not trained in insurance appeals. Claimable specializes in legal argumentation and persuasive writing, often outperforming standard doctor-written appeals in terms of depth, thoroughness, and compliance with legal standards.

That said, your doctor can still support your appeal process. Learn more about how best to work with your doctor here. 

How Is This Different From ChatGPT and Similar Platforms? 

Unlike general-purpose AI models like ChatGPT, Claimable is specifically designed for medical legal appeals, making it far more effective and precise for your specific needs.

It not only stays updated with the latest medical evidence, legal changes and recent case developments but is also built to comply strictly with HIPAA regulations. This ensures that all your personal and medical information is handled with the utmost security and confidentiality, safeguarding your privacy throughout the process. This tailored focus and commitment to compliance make Claimable uniquely reliable and secure for handling sensitive medical appeals.

Is My Health Information Safe? 

All of your data is handled with strict adherence to HIPAA regulations, ensuring your personal information is protected with the highest standards of security and confidentiality. Claimable uses encrypted data storage and transmission protocols to safeguard your information from unauthorized access.

When it comes to insurance appeals, we believe everyone is entitled to fast, affordable, effective support.

Lawyers are expensive, and doing it yourself takes huge amounts of time and expertise that most of us just don’t have. By leveraging Claimable’s AI-powered platform, you have access to a powerful, efficient, cost-effective, and safe solution, right in the palm of your hand. Insurers are making technology work for them, it’s time you do too.

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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

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