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If your insurer hasn't responded to your appeal, discover how to check status and enforce review deadlines.

We know how frustrating it is to feel ignored by your insurance company, especially when your health is on the line. But you don’t have to wait endlessly—your insurer is legally required to review and respond to your appeal within set timelines.

If you haven't heard back about your appeal–here's how to hold them accountable and make sure they stick to their deadlines.

Quick Summary – More details below:

1. Call member services for a status update—you deserve quick answers.
2. Use the tips below to get results and avoid delay tactics.
3. If you're being ignored, file a complaint with their regulator—they’re there to help!

"Never give in, never give in, never, never, never, never—in nothing, great or small, large or petty—never give in except to convictions of honor and good sense."
–Winston Churchill

How long does my insurer have to review my appeal?

The Affordable Care Act and ERISA regulations set strict rules for how appeals are handled: who reviews your appeal, how and when they must share decisions, and the specific timelines they must follow. Below are the general review timelines, but be sure to check your denial letter for specifics to your plan.

Below are the required timelines for various types of appeals.

• Expedited Service: 72 hours
• Experimental Service: 7 days
• Prior Authorization: 15 days
• Upcoming Service: 30 days
• Received Service: 60 days

You can request an expedited appeal if waiting for a claim decision may put your health at risk, such as if you urgently require medication due to a risk to health or severe pain, or are currently in the hospital. Formulary exceptions also qualify for 72 hours reviews, when you request a treatment not covered by your plan because it is medically necessary.

How do I know when my appeal was received?

We submit your appeal via Fax and First-Class Mail with tracking to ensure delivery. You’ll receive an email receipt confirming when your appeal was faxed, and mail delivery typically takes 3-5 days. If there’s an issue with delivery, we’ll let you know and work on alternative methods. If you need a detailed tracking report–reach out to support@getclaimable.com.

How can I find out my appeal status?

Call the member services number on the back of your insurance card and ask for an update on your appeal. Sometimes your provider may receive updates faster, so it’s worth checking with them too.

Can Claimable contact my insurer for me?

Your appeal is 100% yours—Claimable helps you create and send it, but we don’t contact your insurer directly or receive updates on your behalf. Because of this, you, in addition to your health provider, will be the ones to receive any updates or decisions from your insurance company.

How Can I Check My Appeal Status?

Unfortunately, insurers often use delay tactics to avoid processing appeals. Here’s how to handle common excuses:

They say: “We never received your appeal.”

You say: “I have proof it was received on [date] at [fax number] and on [date] at [address]. Please check again. I’ve also copied regulators, your CEO, and other decision-makers. Let me know if you need a detailed tracking report.”

They say: “We need more time to review.”

You say: “No, unless you can provide a valid reason in writing today that meets legal criteria for an extension. The law requires a decision within [review days], and I’ll file a complaint with [regulator] if there’s no compliance.”

They say: “You can’t appeal.”

You say: “Under the Affordable Care Act (or ERISA for self-funded plans), I have the right to appeal, including requesting exceptions to plan policies like step therapy or formularies when medically necessary. I am entitled to my own internal and external appeals, in addition to any requests or appeals sent by my health provider.”

What If I Don’t Hear Back?

Ignoring appeals is illegal. If your insurer doesn’t respond within the required timeline, you should file a complaint with your regulator—typically your state's Insurance Commissioner or the Department of Labor if you're on a self-funded plan.

Here's a breakdown of who to file a complaint with, depending on your plan type:

• 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

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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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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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