Denials, Prior Authorizations, and Appeals

What happens when you need a medication or medical care that isn't automatically covered by your insurance?  First, DON'T PANIC!  You will need to advocate for yourself, which may require you to do your own research on the medication, test, procedure, etc.  It can feel overwhelming and scary, but no one cares about your health and well-being more than you do!

Guidebook Templates Samples Medicare Appeals Process

Filing Prior Authorizations and Appeals: A Step-by-Step Guide

1. Record Your Interactions (If Allowed)

• Check if your state is a "one-party consent" state. If it is, you can legally record your conversations as long as you are part of the call.
  If allowed, consider downloading an app like Cube ACR to record phone calls with your insurance company. You can then use a site like TurboScribe to transcribe your calls, making it easier to keep track of important details.

• If you use online chat instead of phone calls, save the chat transcripts in a Word or Google Doc for your records.

• Also, use an Excel or Google Sheets document to log all interactions with your insurance company. You can find a template for this under the "Templates" section of this website.

2. Request a Prior Authorization

If your medication or service is denied, contact your doctor or their office and ask them to submit a prior authorization. You cannot do this yourself—it must come from your doctor.

There are two types of prior authorizations:

• Standard: Normal review time.

• Expedited (Urgent): For situations where waiting could seriously impact your health.

Your doctor’s office can submit a prior authorization in several ways:

• By calling your insurance company.

• Digitally, through your insurer’s provider portal.

• Through CoverMyMeds (for medications).

• By requesting a peer-to-peer review with an insurance company doctor.

3. If Denied: File an Appeal

If the prior authorization is denied, you (or your doctor) can file an appeal. Like prior authorizations, there are standard and expedited appeals.

You can file the appeal yourself, and instructions will be included with the denial letter. 

Appeals can be submitted in several ways:

• By phone (verbal appeal to the insurance company’s appeals department)

• In writing

• With a Letter of Medical Necessity from your doctor

4. If the First Appeal Is Denied: File a Second-Level Appeal

If your first appeal is denied, you or your doctor can file a second-level appeal. This review is handled by a third-party company, not your insurance provider.

Instructions and contact info for this step are included in the denial letter. You’ll likely need to send:

• All documents submitted to the insurance company

• Any new or additional information that supports your case

5. File a Grievance

If you’re unhappy with how the insurance company handled your case (regardless of the appeal outcome), you can file a grievance—a formal complaint.

You can file a grievance:

• With your insurance company

• With Medicare

• With AARP, if you’re a member

You can do this anytime, but if your second-level appeal is denied and the grievance doesn’t lead to a resolution, you can file a formal complaint with Medicare. For help, contact the State Health Insurance Assistance Program (SHIP) through the National Association of Insurance Commissioners (NAIC).

6. If All Else Fails: Request a Hearing

If your second-level appeal is denied, you can request a hearing with an Administrative Law Judge (ALJ) as a third-level appeal through OMHA (Office of Medicare Hearings and Appeals).

Follow the instructions included with your second-level denial letter to move forward with this step.

***If you need help researching or organizing your thoughts and legal points, try using ChatGPT.  You can even ask it to help you prepare by giving you possible questions and answers that you might be asked.***

HHS - Requesting an ALJ Hearing FAQs

OMHA e-Appeal Portal (Click "Sign in with ID.me") 

ALJ Appeal Status Information System Inquiry Page 

Quick Tips

• Stay organized: log every phone call, letter, or email.

• Always ask for names, dates, and reference numbers.

• Don’t be afraid to escalate if you're not getting the help you need.

• Be persistent—appeals often get approved when the right documentation is submitted.

• Keep Your Copies - Keep copies of everything, including your own medical records, and keep them organized. 

• Don't be afraid to demand what is rightfully yours, like your "case file".