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Appealing a Decision Made by Your Health Insurer

Appealing a Decision Made by Your Health Insurer

When you receive a medical service, like a check-up with a doctor or an emergency room visit, you or your health care provider will submit a request for payment to your health insurer. This request is known as a claim.

If your claim is initially denied, you may be able to get the claim paid by taking the following steps. If you need care immediately, view the expedited external appeal section.

Step 1: Internal Appeal to your insurer

Ask your insurer to conduct a full and fair review of its initial decision. This is called an internal appeal.

  • The denial notice you received will tell you the process you must follow, including how long you have to submit the internal appeal to your health insurer. Failure to submit your appeal within the timeframe listed in the notice may invalidate your claim. Call your health insurer if you do not understand how to submit an internal appeal.
  • After you submit your internal appeal, your health insurer is required to tell you its final decision within:
    • 30 calendar days for a health care service that has been scheduled but you have not yet received (a pre-service denial).
    • 60 calendar days for a health care service you have already received (a post-service denial).

Step 2: External Appeal to DIFS

If you disagree with your insurer’s final decision, you may submit an appeal to DIFS. This is called an external appeal.

  • The appeal must be submitted within 127 days of the final decision.
  • External appeals can be filed with DIFS using either the online form or the paper form (PDF).
  • You may file your own appeal or you may authorize another person, such as a doctor, attorney, parent, or spouse, to represent you.
  • Be sure to include the following with your appeal:
    • A copy of the final denial from your health insurer;
    • The reason(s) why you are appealing the decision; and
    • Any documentation you have to support your appeal.
  • When the DIFS external appeal process is completed, both you and the insurer will receive written notice of DIFS’ decision.

Expedited Appeals

If your claim has been denied and you need care immediately to protect your life, health, or ability to regain maximum function, you may be able to file a DIFS expedited external appeal.

  • An expedited external appeal is conducted by DIFS within 72 hours.
  • Expedited external appeals can be requested using either the online form or the paper form (PDF).
  • Your appeal must include a letter from your treating physician verifying the necessity of an expedited review.
  • You can only request an expedited external appeal for pre-service denial. Post-service denials are not eligible for an expedited appeal.

For more information about the DIFS external appeal process, contact DIFS at 877-999-6442, Monday through Friday from 8 a.m. to 5 p.m.

Health Insurance Appeals Forms

Frequently Asked Questions

  • An adverse determination, also known as a denial, is typically a letter or electronic document that informs you that your claim, or part of your claim, has been denied. It is also considered a denial if your health insurer does not respond to your claim in a timely fashion.

    If you disagree with the decision listed in the adverse determination, you can begin the appeal process by filing an internal appeal with your health insurer.

  • If you complete your health insurer’s internal appeal process and you still disagree with its decision, you can file an external appeal with DIFS using either using the online form or the paper form (PDF) within 127 days from the date of the final adverse determination from your health insurer.

  • You may file your own appeal, or you may authorize any person, such as a doctor, attorney, parent, or spouse, to represent you in the internal and/or external appeal process:

    • For internal appeals: Contact your health insurer for more information on how to name your authorized representative.
    • For DIFS external appeals: The DIFS External Appeal online form and the paper form (PDF) provide space to name an authorized representative. The person you list will be DIFS' sole contact during the external appeal process.

  • The timeline for the internal appeal process after you have submitted your appeal will vary depending on your insurer, but may not exceed:

    • 30 calendar days for a health care service that has been scheduled but not yet completed (a pre-service denial)
    • 60 calendar days for a health care service you have already received (a post-service denial).

    For a DIFS external appeal, the process varies depending on the nature and complexity of the claim. For appeals filed under the DIFS expedited external appeal process, as listed above, the process will be completed within 72 hours of receiving the appeal request.

  • Generally, health plans do not cover experimental or investigational treatments. If you disagree with a decision your health insurer made regarding your health care claim, you have the right to file an internal appeal, and the health insurer is required to conduct a full and fair review of its initial decision.

    If you choose to file an external appeal for a denial based on an experimental and/or investigational service, your treating provider must complete the DIFS Treating Provider Certification for Experimental/Investigational Denials form and you must submit it with your request.