This post doesn’t cover Medicaid or Medicare; those have separate processes. Have an employer plan or marketplace plan? Keep reading. For those of you continuing to read, there will be a second fork later, and we'll handle it when it matters.

Barbara is a superhero. Her husband has cancer, and she has been dealing with the emotional weight, has been his number one supporter through the process, and has also been juggling the day-to-day stuff of life. In addition to this, she was trying to get her husband's cancer treatment paid for by insurance, like any other wife, husband, or parent in the same situation. The problem? Her and her husband's insurance health plan sent her a letter in the mail. That physician-prescribed cancer treatment to keep her husband alive? DENIED. Sadly, Barbara and her husband aren't alone. According to a 2026 KFF poll, 33% of insured adults report having had a denial of a prescribed medication or service in just the last two years. Here's how to use your federal protections to fight back against a denial, and it starts with an internal appeal.

If you requested coverage or filed a claim with your health plan and were denied, you're eligible to file for an internal appeal. Your insurance company has to notify you within a federally-mandated timeframe, depending on your situation:

One exception: these federal rights apply to non-grandfathered plans. If your plan has been around and largely unchanged since March 2010, it may be grandfathered and exempt — your plan documents will tell you.

To file an appeal, first look to your denial letter (and make sure you keep this as well as all papers relevant to your medical service(s) and/or claim). The denial letter will tell you exactly how to appeal, per federal guidelines. Just a heads up: the process will likely be arduous and painful. Of note: you must request an internal appeal within 180 days of receiving the denial letter.

Once you've filed it, the internal appeal will be completed within 30 or 60 days, depending on whether you've already received service (60 days if you've already received the service). Once they've made their decision, the insurance company must provide written notice of it. If they've denied you a final time, your needs are urgent, or your plan didn't follow its own appeal rules, you have the right to request an external, or independent, review.

First, let's define an external review. An external review (also called an independent review) is where a third-party company (AKA not your health insurance company) looks over all of the documentation related to your claim/coverage denial; the health insurance company has to provide them this information within five business days, and you are able (and I encourage you) to submit your own documentation to the independent reviewer.

Two things make this worth your time. First, the decision is binding — your insurance company is required by law to accept it. Second, it's free. The federal process costs you nothing. State processes may charge a filing fee, but it's capped at $25, refunded if you win, waived if paying it would be a hardship, and capped at $75 per year.

Of note: you must request an external review within four months of receiving your final denial letter.

Back to the fork. You have an employer or marketplace plan. Now you need to determine whether the policy is fully insured or self-funded/self-insured. Both would look exactly the same to you; you'd still have the same Aetna card, network, portal, etc. The easiest way to find out which you are is to ask your HR representative or call your insurance provider, and it's an incredibly important distinction to make! If you're on a fully insured plan, you will file your external review through the state process. If you're on a self-funded plan, you would use the federal route (and would not be able to file a complaint with your state insurance department, and state coverage mandates don't apply) since you're under the Employee Retirement Income Security Act of 1974 (ERISA).

One more wrinkle on the federal route: it comes in two versions. Some plans use the government-run process (MAXIMUS, below), and others contract with a private independent review organization instead. Your denial letter names which one handles your review, so check there before you call anyone.

In addition, a few states and territories don't have their own process (yet), so you'd have to file your external review request with the federal government anyway. As of this writing (October 2026), the states/territories that require you to file with the federal government are: Alabama, Florida, Georgia, Texas, Wisconsin, American Samoa, Guam, Northern Mariana Islands, and the Virgin Islands. This list does change — Arizona moved off it in 2025 — so check the current version before you file.

Federal Process: Visit the official MAXIMUS external review site or call 888-866-6205. For MAXIMUS reviews, the reviewer will make their final decision within 45 days of the request's submission. For situations deemed truly urgent, the MAXIMUS reviewer will conduct an expedited review and make a final decision within 72 hours of receiving the request.

State Process: Depends heavily on the state. Here are links to each state's webpage related to external reviews. Some have forms that are easily found; if you don't see a form on that page immediately, call their number, usually at the bottom of the page.

If the paperwork is more than you can carry right now, there are people whose entire job is to carry it with you, for free:

If you filed for an internal appeal or an external review and are willing to share more about your experience, please let me know! Leave a comment here, and I'll reach out. Insurance denials cannot only be stressful but also have negative ramifications for our financial stability. Subscribe here for more on medical bills, debt, and staying financially intact.