Frequently Asked Questions

No. Filing an internal appeal is always free. Your insurer cannot charge you for exercising your appeal rights.

For external review (the independent review after your internal appeal is denied):

• Under federal rules, the external review fee is either free or a maximum of $25
• If you win the external review, the $25 fee (if charged) is refunded
• Many states have eliminated the fee entirely
• New York charges $25, refunded if overturned
• California's Independent Medical Review is completely free

You do not need to hire a lawyer to appeal, though legal assistance can be helpful for complex cases, especially ERISA appeals. Some patient advocacy organizations and state Consumer Assistance Programs provide free help.

Yes, absolutely. The majority of successful appeals are filed by patients themselves or by their doctors on their behalf. The appeal process is designed to be accessible without legal representation.

That said, there are situations where legal help can make a difference:

• ERISA plans: If your employer self-funds its health plan, the appeal is governed by ERISA, which has stricter requirements. An ERISA attorney can help ensure you build a complete administrative record, which is critical because if you later go to court, the judge can only consider evidence that was in the record during the appeal
• Large dollar amounts: If the denied treatment costs tens of thousands of dollars, an attorney or professional patient advocate may be worth the investment
• Repeated denials: If you have exhausted your internal appeals and external review, legal action may be the next step

Before hiring a lawyer, check if your state has a Consumer Assistance Program that provides free help. Many states do.

Success rates vary significantly by denial type, insurer, and whether you reach external review. Here are the ranges based on published data:

• Coding errors: ~78% success rate -- the easiest to overturn because they are often simple mistakes
• Prior authorization denials: ~65% success rate -- particularly when physician peer-to-peer review is used
• Step therapy/formulary denials: ~60% success rate -- especially strong when you can document prior treatment failures
• Medical necessity denials: ~55% success rate -- requires the most comprehensive evidence
• Out-of-network denials: ~50% success rate -- improved significantly since the No Surprises Act
• External review (all types): 44-54% overturn rate nationally, but up to 60% in states like California

The key takeaway: nearly half or more of appeals succeed across every denial type. The single biggest factor in success is simply filing the appeal. Less than 1% of patients appeal, and insurers know this. The system is designed to discourage you from trying. Do not let it.

If your internal appeal is denied, you are not out of options. In fact, the next step -- external review -- is often more favorable than the internal appeal.

External review means an independent third party (not your insurer) reviews your case. The key facts:

• The external reviewer is an Independent Review Organization (IRO) with no financial relationship with your insurer
• The IRO's decision is legally binding on the insurer -- if they say your claim should be covered, the insurer must pay
• External review is free or costs a maximum of $25 (refunded if you win)
• Standard reviews take up to 45 days; expedited reviews take 72 hours or less
• External review is available for medical necessity denials, experimental/investigational denials, and rescissions

Beyond external review, additional options include:

• State Department of Insurance complaint: If you believe the insurer violated regulations, file a formal complaint. Your state DOI can investigate and take action
• Medicare appeals (for Medicare Advantage plans): You can escalate through multiple levels: IRE, Administrative Law Judge, Medicare Appeals Council, and federal court
• Legal action: For ERISA plans, you can sue in federal court. For non-ERISA plans, state court may be an option. Consult an attorney
• Media and advocacy: In some cases, media attention on insurer practices has prompted reconsideration. Patient advocacy organizations can also help

ClearCost Appeals can generate both external review requests and DOI complaints from the Escalate page.

Recommended but not required. You have the legal right to file an appeal on your own. However, physician involvement dramatically improves your chances.

Here is how your doctor can help:

• Letter of Medical Necessity (LOMN): A letter from your treating physician explaining in clinical terms why the treatment is medically necessary for your specific condition. ClearCost Appeals generates a draft LOMN that your doctor can review and sign
• Peer-to-peer review: Your doctor can request to speak directly with the insurer's medical director. This is often the fastest way to overturn a prior authorization denial. Many denials are overturned at the peer-to-peer stage without a formal appeal
• Medical records: Your doctor can provide the clinical documentation, test results, and treatment history that support the appeal
• Specialist opinion: If the insurer's reviewer was not in the same specialty as your doctor, having a specialist write a supporting letter is particularly powerful

The No Surprises Act is a federal law that took effect on January 1, 2022 (codified at 42 USC 300gg-111). It protects patients from unexpected out-of-network medical bills in three key situations:

• Emergency services: If you go to the emergency room, you cannot be balance billed by out-of-network providers at that facility. You pay only your in-network cost-sharing amount, regardless of whether the ER, doctors, or specialists are in your network
• Non-emergency services at in-network facilities: If you receive care at a hospital or facility that is in your network, but an individual provider (anesthesiologist, radiologist, pathologist, assistant surgeon, etc.) is out of network, you are protected from balance billing by that provider. You did not choose them and may not have even known they were out of network
• Air ambulance services: Out-of-network air ambulance providers cannot balance bill you beyond your in-network cost-sharing

What the No Surprises Act does NOT cover:

• Ground ambulance services (a major gap in the law)
• Scheduled, non-emergency care at an out-of-network facility where you were informed in advance and consented in writing
• Post-stabilization care if you were properly informed and consented to OON treatment

If you received a surprise out-of-network bill in one of the protected situations, you can dispute it. The law creates an Independent Dispute Resolution (IDR) process between the provider and insurer, and you should not be billed more than your in-network cost-sharing. If your insurer is trying to make you pay the OON amount, cite the No Surprises Act in your appeal.

ERISA (Employee Retirement Income Security Act of 1974) is a federal law that governs employer-sponsored benefit plans, including health insurance. If your health insurance is through a private-sector employer that self-funds its health plan, ERISA likely governs your appeal rights instead of state law.

Why it matters:

• State laws may not apply: ERISA preempts (overrides) state insurance regulations for self-funded employer plans. This means your state's enhanced consumer protections, like stronger external review or Consumer Assistance Programs, may not be available to you
• Administrative record is critical: If your ERISA appeal is denied and you go to court, the judge generally can only consider evidence that was part of the administrative record during your appeal. You cannot introduce new evidence later. This makes it essential to build a comprehensive record during the appeal itself
• Damages are limited: Under ERISA, if you sue and win, you generally can only recover the value of the denied benefits -- not punitive damages or emotional distress damages
• Federal external review still applies: Even for ERISA plans, the ACA requires access to external review for medical necessity and rescission disputes

Which plans are ERISA plans?

• Most large employer plans where the employer self-funds (pays claims directly) are ERISA plans
• Government employer plans (federal, state, local) are generally NOT subject to ERISA
• Church plans may be exempt from ERISA
• Individual and marketplace plans are NOT ERISA plans
• Small employer plans that are fully insured (the insurer bears the risk) are technically ERISA plans but are also subject to state regulation

ClearCost Appeals determines whether ERISA likely applies based on your plan information and adjusts the appeal strategy accordingly.

Federal law sets maximum response times. If your insurer exceeds these, they are in violation:

• Pre-service urgent claims: 72 hours (the insurer must decide within 72 hours)
• Pre-service non-urgent claims: 30 days for the initial decision, 30 days for the appeal
• Post-service claims: 60 days for the appeal decision
• Expedited external review: 72 hours (or 24 hours in some states for life-threatening situations)
• Standard external review: 45 days

If the insurer misses these deadlines, you may be able to:

• Consider the internal appeal "exhausted" and proceed directly to external review
• File a complaint with your state Department of Insurance for the deadline violation
• Use the missed deadline as additional leverage in your appeal or complaint

Yes, and you should. The appeal is your opportunity to submit additional evidence that was not available or not included when the original claim was filed. In fact, most successful appeals include new information that addresses the specific reason for the denial.

Types of new evidence to include:

• Letter of Medical Necessity from your doctor (ClearCost Appeals generates a draft)
• Medical records showing the clinical basis for the treatment
• Lab results and imaging supporting the diagnosis
• Documentation of prior treatments that were tried and failed
• Peer-reviewed medical literature supporting the treatment (ClearCost Appeals finds these)
• The insurer's own coverage policy showing you meet the criteria (ClearCost Appeals looks this up)
• Letters from other treating physicians supporting the recommended treatment