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My insurance denied coverage. What now?

First steps after a coverage denial: read the reason, then appeal.

Updated Sep 26, 2026

Denials are common, and you can usually appeal. Start with two things:

  1. Read the denial notice for the specific reason. It will usually cite a missing prior authorization, a step-therapy rule, or a formulary exclusion, and each one has a different next step. Our guide to understanding insurance coverage explains what those terms mean.
  2. Ask your prescriber about an appeal. The office can submit additional documentation or a letter of medical necessity with it. Few people appeal, but appeals do sometimes work: in HealthCare.gov plans in 2024, insurers reversed about a third of the denials that consumers appealed internally, according to KFF.

Most plans have both an internal appeal and, if that fails, an external review by an independent party. For help with the next steps:

Keep copies of everything and note deadlines, because appeal windows are time-limited. Under federal rules for most plans, you have 180 days from the denial notice to file an internal appeal.

This is general information, not medical advice. Appeal rights and timelines depend on your plan and where you live; confirm the specifics with your insurer.

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Common questions

Questions people often ask about this topic.

  • What should I do first after a coverage denial?

    Denials are common, and you can usually appeal. First, read the denial notice for the specific reason. It will usually cite a missing prior authorization, a step-therapy rule, or a formulary exclusion, and each has a different next step. Then ask your prescriber about an appeal; the office can submit additional documentation or a letter of medical necessity.

  • Can a coverage denial be appealed?

    Yes. Most plans have both an internal appeal and, if that fails, an external review by an independent party. Appeals do sometimes work: in HealthCare.gov plans in 2024, insurers reversed about a third of the denials that consumers appealed internally, according to KFF. Appeal rights and timelines depend on your plan and where you live, so confirm the specifics with your insurer.

  • How long do I have to appeal a denial?

    Appeal windows are time-limited, so note the deadlines and keep copies of everything. Under federal rules for most plans, you have 180 days from the denial notice to file an internal appeal. Exact timelines depend on your plan and where you live, so confirm them directly with your insurer so you don't miss a window.

Evidence: For & Against

Both sides of the topic, so you can weigh the evidence yourself.

2Supporting

  • Internal appeals — HealthCare.gov (external link)

    HealthCare.gov (CMS) · Clinical guideline · Strong evidence

    (2026)

    Federal consumer guidance: file an internal appeal within 180 days of the denial notice; insurer must decide within 30 days for services not yet received or 60 days for services already received; external review by an independent party is available if the internal appeal is denied (urgent cases can request both at once).

  • Claims Denials and Appeals in ACA Marketplace Plans in 2024 (external link)

    KFF · Reporting · Moderate evidence

    Long M, Lo J, Pestaina K (2026)

    Published March 24, 2026. HealthCare.gov consumers appealed fewer than 1% of about 85 million in-network denied claims in 2024; insurers upheld 66% of internal appeals, so about a third were reversed. Data cover HealthCare.gov marketplace plans only.

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    Related terms

    • External review — An independent, outside review of an insurer's denial after internal appeals are exhausted, with a decision the plan must follow.
    • Formulary exception — A request asking your plan to cover a drug that isn't on its formulary, or to cover it at a lower tier, based on medical need.
    • Letter of medical necessity — A prescriber's written statement explaining why a specific medication is medically required for a patient, used to support prior authorization and appeals.
    • ERISA (Employee Retirement Income Security Act) — The federal law governing most employer-sponsored health plans, which largely exempts self-funded plans from state insurance mandates and sets the rules for claims and appeals.
    • Open enrollment — The annual window when you can enroll in or change your health plan, and the time to compare GLP-1 coverage across the plans available to you.
    • P&T committee (Pharmacy and Therapeutics committee) — The panel of physicians, pharmacists, and other clinicians that reviews the clinical evidence behind a plan's formulary: which drugs are acceptable, which are interchangeable, and what restrictions apply.