Insurance Appeal Resources

Patient Advocacy Organizations

Nonprofit organizations that help patients navigate insurance disputes.

• Patient Advocate Foundation
  Free case management, mediation, and financial aid for patients with chronic, life-threatening, or debilitating conditions.
• Patient Rights Advocate
  Works to make healthcare prices transparent and protect patients from surprise billing.
• Kaiser Family Foundation (KFF)
  Independent health policy research. Publishes key data on denial rates, appeal success rates, and insurer practices.
• Families USA
  National nonprofit dedicated to achieving high-quality, affordable health care and coverage for all.
• Catalyst for Payment Reform
  Works to improve how healthcare is paid for, making quality and value more transparent.
• National Alliance on Mental Illness (NAMI)
  Advocacy for mental health coverage, parity law enforcement, and appeal assistance for mental health denials.

Federal Government Resources

Government agencies with authority over health insurance practices.

• Medicare: filing an appeal
  Official Medicare appeals process: 5 levels of appeals for Medicare beneficiaries, including Administrative Law Judge hearings.
• CMS Medicare Coverage Database
  Search National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) to find coverage criteria for specific procedures.
• Department of Labor — claims and appeals rule
  Your rights under ERISA Section 503 for employer-sponsored health plans. How to file a full and fair review of denied claims.
• DOL: help for workers and families
  Comprehensive guide from the Department of Labor explaining your health care rights under federal law.
• HHS: Affordable Care Act Overview
  Understanding ACA protections including the right to internal and external appeal of denied claims (42 USC 300gg-19).
• CMS No Surprises Act Information
  Federal protections against surprise medical bills, including the Independent Dispute Resolution (IDR) process.
• No Surprises Help Desk
  Call 1-800-985-3059. Federal help desk for consumers who received surprise medical bills or need help with IDR.

NAIC & Consumer Complaints

File formal complaints about insurance company practices.

• NAIC directory of state insurance departments
  National Association of Insurance Commissioners directory, to find your state's insurance department and its complaint process.
• Healthcare.gov External Review Guide
  Federal guide on requesting an independent external review of your insurer's decision under the ACA.

Mental Health Parity Resources

Resources for fighting mental health and substance use disorder coverage denials.

• DOL: Mental Health Parity Act
  Federal Mental Health Parity and Addiction Equity Act (MHPAEA) — requires equal coverage for mental health and medical/surgical benefits.
• ParityTrack
  Kennedy Forum initiative tracking state mental health parity laws and enforcement. Find your state's parity protections.
• National Council for Mental Wellbeing
  Advocacy and resources for behavioral health organizations and the patients they serve.

State Insurance Department Contacts (All 50 States)

Your state insurance commissioner regulates health insurers in your state. File a complaint if your insurer acts in bad faith.

Legal Resources & Self-Help

Legal information and tools for understanding your appeal rights.

• ERISA Section 503 (29 USC 1133) — Full Text
  The federal law requiring employer-sponsored health plans to provide full and fair review of denied claims.
• ACA Section 2719 (42 USC 300gg-19) — Full Text
  The Affordable Care Act provision guaranteeing your right to internal and external review of denied claims.
• Healthcare.gov: How to Appeal
  Official federal guide to appealing health insurance company decisions, including timelines and sample letters.
• CMS External Appeals Information
  Information about federally-facilitated external review for states that have not established their own process.

Medical Literature & Evidence

Search tools for finding clinical evidence to support your appeal.

• PubMed (NCBI)
  Free database of biomedical citations from the National Library of Medicine. Search for peer-reviewed studies supporting the medical necessity of your treatment.
• ClinicalTrials.gov
  Database of clinical studies. Useful for showing that a treatment is being actively studied and is not purely "experimental."
• DailyMed (NIH)
  FDA-approved drug labeling. Find official indications, contraindications, and clinical pharmacology for medications.
• NCCN Clinical Practice Guidelines
  National Comprehensive Cancer Network guidelines. The gold standard for cancer treatment coverage determinations.