How to Get Care Covered and Appeal a Denial

Written by Aptiva Health Editorial Team · Reviewed by Taylor Sorrels, Esq. and Crystal Brake, RCM Director · Editorial & review standards · How we research

Getting a “no” from your health plan is stressful. It can feel final. Most of the time, it isn’t.

Health plans have to tell you why they said no. They also have to give you a way to ask them to look again. If they still say no, many people can ask an outside reviewer who does not work for the plan. That outside step is called an external review.

This guide walks you through the whole process. It is written for patients in Kentucky and Indiana, but most of it applies anywhere in the U.S. You will learn how coverage decisions get made, what the common denial reasons really mean, which appeal route your plan uses, and what to send.

How a coverage decision gets made

Coverage decisions usually happen in a chain. Knowing where you are in the chain tells you what to do next.

1. Your clinician orders care. For example, an MRI, physical therapy, or an injection.
2. The plan may require prior authorization. Some services need the plan’s approval before you get them. This is also called “pre-authorization” or “pre-cert.” See how prior authorization works.
3. You get the care, and the provider sends a claim. A claim is the bill your provider sends to your plan.
4. The plan pays, pays part, or denies. You get an Explanation of Benefits (EOB) that shows what happened.
5. You can appeal a denial. First to the plan (an internal appeal), then often to an independent reviewer (an external review).

A denial can happen at step 2 (the plan won’t approve the care ahead of time) or at step 4 (the plan won’t pay the claim). You can appeal either one.

What changed in 2026

A federal rule called CMS-0057-F changed prior authorization for many plans starting January 1, 2026. Its time limits apply to Medicare Advantage plans and to Medicaid and CHIP (CMS: CMS-0057-F fact sheet). Under the rule, these plans must:

• Decide urgent prior authorization requests within 72 hours.
• Decide standard requests within 7 calendar days.
• Give a specific reason when they deny a request.
• Publish data about their prior authorization decisions in 2026.

The same rule requires these plans to build electronic prior authorization systems by January 1, 2027. Plans on the federal ACA Marketplace must also give a specific denial reason, but the 72-hour and 7-day limits don’t apply to them.

Many large insurers also made voluntary promises in June 2025 (CMS press release, June 23, 2025). Those promises include clearer denial explanations. They also include a 90-day transition period for prior authorizations when you switch plans, starting in January 2026. These are industry promises, not laws. Ask your plan how it applies them.

Read your denial and your EOB first

Before you do anything else, find two documents:

• The denial letter (sometimes called an “adverse benefit determination”). This is the plan’s official notice.
• Your Explanation of Benefits (EOB). This is not a bill. It shows what the provider charged, what the plan allowed, and what you may owe. Learn how to read your EOB.

On the denial letter, look for these five things and write them down:

1. The exact reason for the denial. Copy the words. They tell you what evidence to send.
2. The service that was denied and the date.
3. Your deadline to appeal. This is the most important date on the page.
4. Where and how to send the appeal. Mail, fax, or an online portal.
5. Whether you can ask for an expedited (urgent) review.

If the letter is vague, call the plan and ask for the specific reason in writing. You can also ask for a copy of the medical policy or guideline the plan used to decide (29 CFR 2560.503-1(g)(1)(v)). Plans usually call these “clinical criteria” or “coverage policies.”

The six reasons claims get denied

Denials usually fall into one of six groups. Each one is beaten a different way.

Start with the reason on your letter. These guides go deeper on the two most common:

• Denied as “not medically necessary”
• Denied for missing prior authorization

Some denials are simple paperwork. A wrong code, a typo in your member ID, or a missing date can cause a “no.” If the reason looks like a billing error, call the provider’s billing office first. A corrected claim is often faster than an appeal.

Which appeal route does your plan use?

The rules for your appeal depend on what kind of plan you have, not just which company runs it. Two people with the same insurance card logo can have different rights.

Look on your insurance card, your plan documents, or ask HR or the plan which type you have.

Fully insured plans and ACA Marketplace plans

These plans are bought from an insurance company. That includes most individual and family plans and many small-employer plans. State insurance law applies to them, and so do federal rules.

Under the federal rule (45 CFR 147.136), you generally have 180 days from the denial to file an internal appeal. After a final internal denial, you can generally ask for an external review within 4 months.

In Kentucky and Indiana, the state’s own external review rules apply to these plans. See the Kentucky guide and the Indiana guide.

Self-funded employer plans (ERISA)

Many large employers pay claims with their own money and hire an insurer only to run the plan. These are “self-funded” plans. A federal law called ERISA governs them.

Self-funded plans generally use the federal external review process, not the state’s (29 CFR 2590.715-2719(c)). Your plan documents should explain the steps. If you are not sure whether your plan is self-funded, ask your HR department or check your plan’s Summary Plan Description (29 CFR 2520.102-3).

Medicare Advantage

Medicare Advantage plans are run by private insurers. Since January 1, 2026, they must follow the CMS-0057-F prior authorization timelines: 72 hours for urgent requests and 7 calendar days for standard ones.

Medicare Advantage has its own appeal levels, separate from the state and ACA process (Medicare.gov: Appeals in Medicare health plans).

Traditional Medicare

Traditional Medicare uses its own appeal process (Medicare.gov: Appeals in Original Medicare).

In 2026, Traditional Medicare began testing an AI-assisted prior authorization model called WISeR in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington (CMS: WISeR Model). Kentucky and Indiana are not in it. The model includes some spinal procedures.

Medicaid managed care

In Kentucky and Indiana, many Medicaid members are in a managed care plan. These plans must follow the CMS-0057-F prior authorization timelines since January 1, 2026. Medicaid also has its own appeal and state fair hearing rules (42 CFR 438.408).

Workers’ compensation

If you were hurt at work, your care is usually handled by your employer’s workers’ comp insurer, not your health plan. Workers’ comp has a completely different appeal ladder run by the state:

• Kentucky: a claim is filed with the Department of Workers’ Claims on an Application for Resolution of a Claim (DWC: How to File a Claim). It is heard by an Administrative Law Judge. You can appeal the judge’s order to the Workers’ Compensation Board within 30 days (120 KAR 1:010).
• Indiana: you file an Application for Adjustment of Claim with the Worker’s Compensation Board of Indiana within 2 years (IC 22-3-3-3). A single hearing member decides, and you can appeal to the Full Board within 30 days (IC 22-3-4-7).

Both state guides cover these steps in more detail.

Auto insurance (PIP)

If you were hurt in a car crash in Kentucky, your auto policy’s personal injury protection (PIP, up to $10,000) may pay first (KRS 304.39-020). Indiana has no PIP; medical payments coverage there is optional (IDOI: Auto Insurance). Auto claims follow your auto policy and state insurance law, not your health plan’s appeal process.

Appeal deadlines at a glance

Deadlines are strict. If you miss one, you can lose the right to appeal. When in doubt, file early.

Your plan’s letter may give a different deadline. Use whichever date comes first, and ask the plan to confirm it in writing.

How to appeal, step by step

1. Find your deadline and reason. Write the appeal deadline on your calendar. Copy the exact denial reason from the letter.
2. Ask for the plan’s rules. Request the medical policy or criteria the plan used, and a copy of your claim file (29 CFR 2560.503-1(h)(2)).
3. Talk to your clinician’s office. Ask them to review the denial reason and write a letter of medical necessity that answers it point by point.
4. Gather your records. Collect visit notes, test results, imaging reports and a list of treatments you already tried.
5. Write your appeal letter. Use the template below. Keep it short and stick to the denial reason.
6. Send it the way the letter says. Use the address, fax or portal on the denial letter. Keep proof that you sent it.
7. Track it. Write down every call: date, name, and a reference number. Follow up if you don’t hear back by the plan’s deadline.
8. Ask for external review if the plan says no again. Do this before the external review deadline.

What to send

A strong appeal packet usually has:

• Your appeal letter (one or two pages).
• A letter of medical necessity from your clinician.
• The denial letter (a copy, not the original).
• Records that answer the denial reason. For example, notes showing six weeks of physical therapy if the plan said you needed to try therapy first.
• The plan’s own policy, with the parts you meet highlighted.
• Any guideline your clinician relies on, such as a professional society guideline.

Do not send original documents. Keep a full copy of everything you send.

What your clinician’s letter should say

A letter of medical necessity is the most important piece. It should:

• Name your diagnosis and the care requested.
• Explain why this care is needed now.
• List what has already been tried and how it went.
• Show how you meet the plan’s own criteria, point by point.
• Explain the risk of waiting or of a cheaper option.

Clinicians’ offices write these often. It is fair to ask for one and to share the plan’s policy with them so the letter matches it.

[Your name]
[Your address]
[Your phone] · [Your email]

[Date]

[Plan name] — Appeals Department
[Address or fax from your denial letter]

RE: Request for internal appeal
Member name: [Name]
Member ID: [Number]
Claim or reference number: [Number from the denial letter]
Service denied: [Service, e.g., MRI of the lumbar spine]
Date of denial letter: [Date]

To the Appeals Department:

I am writing to appeal your decision to deny coverage for [service]. Your letter dated [date] says the reason was: "[copy the exact reason]."

I am asking you to reverse this decision. [Service] is medically necessary for me because [one or two sentences, in plain words — your clinician's letter gives the details].

Enclosed please find:
1. A letter of medical necessity from [clinician name, credentials].
2. My medical records from [dates], showing [what they show].
3. A copy of your medical policy [policy name or number], with the criteria I meet marked.
4. A copy of your denial letter.

Please send me your decision in writing. If you uphold the denial, please tell me the specific reason, the criteria you used, and how to request an external review.

If my condition is urgent, I request an expedited review.

Thank you,
[Signature]
[Printed name]

This sample is a starting point, not legal advice. The Patient Advocate Foundation also publishes a free sample appeal letter (see Sources).

Expedited (urgent) appeals

If waiting could seriously harm your health, you can ask for an expedited review. Your clinician’s support helps. Say “expedited” or “urgent” clearly in your request and on the phone.

Urgent timelines are much shorter:

• Prior authorization (Medicare Advantage and Medicaid, since 2026): 72 hours.
• Kentucky internal appeal: 72 hours. Kentucky external review: within 72 hours at most (KY DOI UM Review Guide (2026)).
• Indiana external review: 72 hours (IC 27-8-29-15).

Peer-to-peer reviews

A “peer-to-peer” is a phone call between your clinician and a doctor who reviews cases for the plan. It can happen before or after a denial. Many denials are reversed on these calls because your clinician can explain details that are not in the chart.

You cannot do the peer-to-peer yourself, but you can ask your clinician’s office whether one is possible and whether it has been scheduled.

External review: the outside check

If the plan denies your internal appeal, you can often ask for an external review. An independent review organization (IRO) looks at your case. It does not work for your health plan.

• Under the federal rule, you generally have 4 months after the final internal denial to ask.
• In Kentucky, you request it through your insurer within 4 months for state-regulated plans. The insurer fills out form HIPMC-IRE-6; you sign a medical-records release (806 KAR 17:290).
• In Indiana, you request it through your insurer within 120 days.
• Self-funded employer plans generally use the federal process, not the state’s.

External review usually applies to medical judgment denials, such as “not medically necessary” or “experimental” (45 CFR 147.136(d); KRS 304.17A-600; IC 27-8-29-12). If the reviewer sides with you, the plan generally must follow the decision (KRS 304.17A-625; IC 27-8-29-16).

Surprise bills and the No Surprises Act

The federal No Surprises Act protects you from many surprise out-of-network bills. For example, it covers emergency care and some care from out-of-network providers at in-network facilities (CMS: Medical bill rights).

Providers and plans settle many payment disputes through a federal process called independent dispute resolution (IDR). A rule announced in May 2026 changed that process. It lowered an administrative fee from $115 to $15 for disputes started on or after June 11, 2026, changed batching rules (up to 50 items per dispute), is moving to a new IDR portal, and requires standard codes on out-of-network payment notices (CMS fact sheet).

If you got a bill you think breaks these rules, contact your plan and the provider’s billing office first.

What Aptiva’s team does for its patients

Aptiva Health’s team handles prior authorization and appeals for our patients in Kentucky and Indiana. That work is part of our care.

In practice, that can include submitting prior authorization requests, gathering the records a plan asks for, and helping with appeals when a plan says no.

If an appeal does not work out, you may still have options. Aptiva publishes cash-pay prices for many services. See cash-pay and self-pay options.

Keep good records

Appeals are won on paper. A simple log protects you.

• Keep every letter, EOB and bill in one folder.
• Write down each call: date, time, who you spoke with, and the reference number.
• Save proof of every appeal you send: fax confirmation, certified-mail receipt, or a portal screenshot.
• Put every deadline on your calendar with a reminder a week early.

How long an appeal takes

It helps to know what to expect, so you can plan your care and your budget. Here is what a typical appeal looks like for a state-regulated plan in Kentucky. Your plan and state may differ.

From start to finish, a standard appeal that goes all the way to external review can take several months. An expedited appeal can take days. That is why it matters to say clearly when a case is urgent.

Common mistakes that sink appeals

Most lost appeals fail for simple, fixable reasons. Avoid these:

• Missing the deadline. This is the most common and the hardest to undo. File early, even if you plan to send more records later.
• Arguing about the wrong thing. If the letter says “no prior authorization,” a long letter about how much pain you are in won’t fix it. Answer the reason on the letter.
• No clinician letter. Your own letter matters, but your clinician’s letter usually carries the most weight.
• Not using the plan’s own rules. Plans decide by their written criteria. Show how you meet each one.
• Sending originals. Always send copies and keep the originals.
• No proof of sending. Keep the fax confirmation, mail receipt or portal screenshot.
• Giving up after the first “no.” An internal denial is often not the end. External review is a separate, independent step.

Where to get help

You don’t have to do this alone.

• Your clinician’s office. They write letters of medical necessity and can request peer-to-peer calls. At Aptiva, our team handles prior authorization and appeals for our patients.
• Your state Department of Insurance. It answers questions about state-regulated plans and takes complaints. Kentucky: (800) 595-6053 (KY DOI Division of Consumer Protection). Indiana: (800) 622-4461 (IDOI Consumer Services).
• Your employer’s HR or benefits team, if your plan comes through work. They can tell you whether it is self-funded.
• Nonprofit patient advocates. Groups such as the Patient Advocate Foundation publish free sample letters and guides (see Sources).
• A lawyer, for workers’ comp disputes, large bills, or complex cases.