All About Appeals

As a consumer on the Health Insurance Marketplace (Healthcare.gov), you have the right to appeal decisions that are not in your favor. There are two types of appeals. The first is an appeal of a Marketplace decision (generally a decision on your eligibility to purchase a plan on Healthcare.gov). The second is an appeal of an insurance company’s decision (usually a decision of whether the company will cover a particular drug or surgery).

Appealing a Health Insurance Marketplace (Healthcare.gov) decision

You have the right to appeal any of the following decisions:

  • Denial of Advanced Payments of the Premium Tax Credit (APTCs) or Cost Sharing Reductions (CSRs)
  • Amount of APTCs or CSRs
  • Adjustment in APTCs or CSRs at end of 90-day inconsistency period
  • Denial of eligibility to enroll in Marketplace coverage
  • Denial of a special enrollment period
  • Termination of Marketplace coverage
  • Denial of coverage exemption
  • Denial of eligibility for Medicaid/CHIP

Important note about eligibility appeals: If the Marketplace says that you are ineligible to buy a plan on Healthcare.gov, you have 90 days to appeal. Learn more about filing an eligibility appeal here.

Fill out appeal forms online here. If you want a family member or another person to represent you in your appeal, find out how to appoint an authorized representative here. After you have submitted your appeal, you can check on the status of your appeal by calling the Marketplace Appeals Hotline (855-231-1751).

How we can help: A Health Insurance Navigator can help you gather information to file your appeal, and our staff can represent you in your appeal at no cost. 

Appealing a health insurance company decision

If your health insurance company refuses to pay for a procedure or a medication, you have the right to appeal. Your health insurance company is required to let you know why they denied coverage, and they must provide you with information on how to appeal.

There are two types of insurance company appeals: Internal appeals and external reviews.

Internal appeals are reviewed by the health insurance company itself. You can file a request for coverage (also known as a claim) either before or after receiving medical attention. If your health insurance company denies coverage of your claim, you must file your appeal within six months of receiving notice that your claim was denied. Follow the instructions that the insurance company includes with their denial. Click here for more information on internal appeals. 

External reviews are the last option to appeal an insurance company’s denial (outside of the legal system), and they are processed by the North Carolina Department of Insurance. External reviews in NC are free. You can reach the Department of Insurance at 855-408-1212, or you can visit their website to request an external review. Click here for more information on external reviews.

Health Insurance Navigators can help you appeal a health insurance company decision and navigate the appeal process with the NC Department of Insurance. 

To get free help from a Charlotte Center for Legal Advocacy Health Insurance Navigator, call 980-256-3782. You can also book an appointment by visiting ncnavigator.net.

If you or someone you know needs health insurance coverage, a Special Open Enrollment Period is open through Aug. 15, 2021. 

Learn more about how to get covered, or call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.