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Insurance denied: out of network. How to appeal
Your health insurance denied a claim as out of network. What it means, your deadline, and how to appeal.
Check my letter freeWhat it means
The provider is not in your plan's network.
What to do
Under the No Surprises Act, emergency care, and care from out-of-network doctors at in-network hospitals, are generally covered at in-network rates.
If no in-network provider was available, ask the plan to cover the care at the in-network level.
Your deadline
Most plans give you 180 days from the denial notice to file an internal appeal. Original Medicare gives 120 days from the Medicare Summary Notice, and Medicare Advantage plans 65 days from their decision. Check the date printed on your letter.
If the plan says no again
After a final denial from a marketplace or employer plan, you can ask for an external review by an independent reviewer within 4 months. If the reviewer decides for you, the plan must pay.
Ask for your claim file
You have the right to receive, free of charge, copies of the documents and the criteria used to decide your claim.
Other denial reasons
- Not medically necessary
- No prior authorization
- Experimental or investigational
- Billing or coding error
- Not covered by your plan
- Claim filed too late
- Other insurance (coordination of benefits)
- Coverage not active