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How to Appeal a Health Insurance Denial in Michigan (2027 Step-by-Step)
A denial isn't the final word. Many denials are overturned on appeal, especially ones caused by coding errors or missing paperwork. Here's the process for ACA-compliant plans, and what's different for other plans.
Step 1: Find out exactly why
Read the denial letter or Explanation of Benefits (EOB). It must state the reason and how to appeal. Common reasons:
- A billing or coding error by the provider
- Missing prior authorization
- "Not medically necessary"
- Out-of-network provider
- The service is excluded from the plan
Call the insurer and the provider's billing office. A coding error can sometimes be fixed with a corrected claim, no appeal needed.
Step 2: File an internal appeal
For ACA-compliant plans, you generally have 180 days from the denial to file. Include:
- The denial letter and your claim or reference number
- A short letter explaining why the service should be covered
- A letter of medical necessity from your doctor, with chart notes and any studies or guidelines
The insurer generally must decide within 30 days for care you haven't received yet and 60 days for care you already got. If waiting could seriously harm your health, ask for an expedited (urgent) appeal, decided within 72 hours.
Step 3: Request an external review
If the internal appeal fails, you can ask for an independent external review, usually within 4 months of the final denial. An outside reviewer decides, and if they side with you, the insurer has to pay.
Step 4: Get help
Michigan Department of Insurance and Financial Services (DIFS) handles consumer complaints and can help with appeals and external reviews for state-regulated plans. Employer self-funded plans fall under federal rules, and the U.S. Department of Labor's benefits advisors can help with those.
Private and non-ACA plans
Private underwritten plans, short-term plans and supplements follow their own policy appeal terms, which may be shorter or different. Read the appeals section of your policy, and file a complaint with Michigan Department of Insurance and Financial Services (DIFS) if you think a claim was mishandled.
Tips that win appeals
- Keep a log of every call: date, name, reference number.
- Cite the plan's own policy language and medical guidelines.
- Ask your doctor for a peer-to-peer review with the insurer's medical director.
- Meet every deadline, and send everything in writing.
Surprise bill instead of a denial? See in-network vs. out-of-network protections. Want help choosing a plan less likely to fight you? Check your options.
Frequently asked questions
How long do I have to appeal a health insurance denial?
For ACA-compliant plans, generally 180 days from the date of the denial notice for an internal appeal.
What is an external review?
An independent review of a denied claim by a third party outside your insurance company. If the reviewer overturns the denial, the insurer must pay.
How fast is an urgent appeal?
Expedited appeals for urgent care must generally be decided within 72 hours.