Appeal a denied insurance claim with AI

Who is this for?

This page is for someone with a denial letter or an explanation of benefits who wants a calm internal appeal before they send it. You bring the paper. The chat quotes the reason, lists what the packet seems to ask for, and drafts a short letter from the lines you pasted. You edit it. You file it.

This is not medical advice. This is not legal advice. This is not financial advice. A chat does not know whether a service was medically necessary, whether your plan is self-funded, or which deadline applies to you. It must not tell you the denial was illegal, name a statute you did not read, or invent a due date.

HealthCare.gov's page on appealing an insurance company decision says that if your insurer refuses to pay a claim or ends your coverage, you have the right to appeal and to have a third party review the decision. It describes two ways. An internal appeal asks the company to conduct a full and fair review. If the case is urgent, the company must speed that process up. An external review is an independent third party, so the company no longer gets the final say on whether to pay. The same page says Marketplace eligibility decisions, such as whether you can enroll or whether you qualify for premium tax credits, are a different appeal. Use the link on that page for those. This guide is the claim denial, not the Marketplace eligibility decision.

CMS's action plan for a denied claim says it applies if your health insurance denied a request for payment and you used Marketplace, employer-sponsored, or other private health coverage. It tells you to ask HR, if the insurance is through an employer, whether the plan is self-funded or fully insured. It says some employers use self-funded plans, the employer takes on the risk, and a health insurance company might only administer the plan. For a self-funded plan, CMS says to ask the employer or the company administering the plan to reconsider the denial or make an exception in accordance with the plan rules. Ask that question before you trust a generic deadline.

A bill you are still trying to read, before any appeal, is Understand a medical bill with AI. The quoting habit is Ask for plain English. The rule that a sentence has to come from the page you pasted is Answer only from your sources.

What do you need before you start?

Gather the papers before you open a chat.

• The denial letter, and the explanation of benefits if you have it. HealthCare.gov says to keep the explanation of benefits or the letters that show what payment or services were denied.
• The itemized bill, if the dispute is about a charge. Black it out the same way as the denial.
• The appeal instructions printed on the denial or in the plan packet, including any form name and any address. You will follow those. The chat will not replace them.
• HealthCare.gov's internal-appeals page and external-review page, so a sentence about a right can be checked against those pages.
• A way to copy the letter. HealthCare.gov says to keep your original documents and submit copies, and that you will need to send the original request for an internal appeal. Keep your own copy of that request too.

You do not need a paid AI plan. You do need the denial. A chat that has not seen the reason is writing fiction.

Leave the member ID, the Social Security number, and the photo of the card out of the chat. Keep your data private with AI. Do this on a personal account. A workplace chat can be visible to your employer. A denial is not a work file unless you are on your own time and the account is one you control. If the only chat you have is a work or school account, do not paste the denial there.

How do you redact the denial before you paste?

Cover these, every time:

• Names, including a patient, a subscriber, and a dependent
• Member IDs and claim numbers, unless you truly cannot refer to the denial without one, in which case leave the letter out of the chat and work from the reason sentence you retyped with the number removed
• A Social Security number, a medical record number, and a date of birth
• A street address, a phone number, and an email address

Keep the date on the letter, the date of service, the denial reason in the insurer's words, the description of the service, and the dollar amounts. If a line is the plan's appeal deadline, keep that sentence. It is the fact the chat is not allowed to invent.

A caller who wants payment by gift card, crypto, a wire, or a payment app is not an appeal. Hang up. Spot AI scams and deepfakes.

How do you quote the denial and list what looks missing?

Paste the redacted reason. Ask for a quote, a plain-English restatement, and a list of documents the letter itself says are missing. If the letter does not say anything is missing, the chat writes NOT ON THE LETTER. It does not invent a doctor's note you "should" have.

HealthCare.gov's internal-appeals page says an insurer must notify you in writing and explain why: within 15 days if you are seeking prior authorization for a treatment, within 30 days for medical services already received, and within 72 hours for urgent care cases. Those are the page's clocks for the denial notice. They are not a deadline you should type into a letter unless your letter is silent and you have read that page and decided it matches your plan. A self-funded plan can be different. CMS tells you to ask HR which kind of plan you have.

The same HealthCare.gov page says you can appeal if the plan will not provide or pay some or all of the cost for services you believe should be covered. It lists examples of reasons: the benefit is not offered, the problem began before you joined, the provider or facility is not in the network, the service is "not medically necessary," the service is "experimental" or "investigative," you are no longer enrolled, or the company is revoking coverage back to enrollment because it claims you gave false or incomplete information. Quote the reason your letter uses. Do not swap in a different one from that list because it sounds stronger.

You are helping me read a denial. This is not medical advice, legal advice, or financial advice. Do not say the denial was wrong. Do not tell me I will win.

I redacted names, member IDs, and Social Security numbers. Use only the lines below.

Quote the denial reason. Then say it in plain English, with no new facts.
Quote any deadline, form name, address, or missing-document sentence. If a deadline is not in the paste, write DEADLINE NOT IN THE PASTE.
List documents the letter says to include. If it names none, write NOT ON THE LETTER.
Do not invent a statute, a phone number, or a dollar amount.
Then stop.

[paste the redacted denial]

Read the quote against the paper. If the plain English adds "illegal" or "they must pay," delete it. The paper said what it said.

Three places to use the same reading. Copy the one that matches you.

Life, when the denial is yours or a family member's and you have their permission to read it:

This is not medical, legal, or financial advice. Do not tell me the insurer was wrong.

The denial is redacted. It is the only source.
Make a table: words quoted from the denial, what I think they mean, and a blank column labeled What I still need.
If the letter does not mention a document, do not add one.
If the letter does not mention a date for the appeal, write DEADLINE NOT IN THE PASTE.
Then stop.

[paste]

School, when you are learning how a denial letter is organized. You write anything you turn in. Follow your teacher's rules. Use a sample, or a letter that is yours and fully redacted.

This is for learning. Do not write anything I will turn in. Follow my teacher's rules. This is not medical, legal, or financial advice.

I am reading this redacted denial:
[paste]

Ask me to explain, in my own words, the reason and whether the page states a deadline.
Wait for my explanation. Then tell me which sentence matches the page and which sentence does not. Quote the line.
Do not write an appeal letter I could turn in. Do not say the denial is unlawful.
Then stop.

Work, on your own time. The denial is still personal. Do not put it in a work chat, and do not draft a note to your employer unless HR is the address printed on a self-funded plan's instructions and you are sending it yourself later.

I am on a personal account. This denial is not a work file. This is not medical, legal, or financial advice.

Redacted lines are below. Quote the reason. List questions I can ask the insurer. Questions only.
Do not draft the appeal yet. Do not mention my job. Do not invent a deadline.
Then stop.

[paste]

How do you read the clocks on HealthCare.gov, then use your letter?

Open the pages. Do not ask the chat to recite them from memory.

Internal appeals says you must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. It says you complete the forms the insurer requires, or you write with your name, claim number, and health insurance ID number, and you submit additional information you want considered, such as a letter from the doctor. It says a Consumer Assistance Program in your state can file an appeal for you. It says the internal appeal must be completed within 30 days if it is for a service you have not received yet, and within 60 days if it is for a service you have already received. At the end, the company must give you a written decision. If it still denies the service or the payment, you can ask for an external review, and the final determination must tell you how.

The same page says that in urgent situations you can request an external review even if you have not finished every internal step, that you can file an expedited appeal if the standard timeline would seriously jeopardize your life or your ability to regain maximum function, and that you may file the internal appeal and the external review at the same time. It says a final decision must come as quickly as your medical condition requires, and at least within 4 business days after the request is received. It says that decision can be delivered verbally, but must be followed by a written notice within 48 hours. If the care is urgent, use those words from the page you have open, and use the insurer's urgent process. Do not let a chat decide that your situation is urgent.

External review says you file a written request within 4 months after the date you receive a notice or a final determination that the claim has been denied. It says the reviewer either upholds the insurer or decides in your favor, and the insurer is required by law to accept that decision. It limits the types it describes: a denial that involves medical judgment, a denial that says a treatment is experimental or investigational, and a cancellation based on the insurer's claim that you gave false or incomplete information when you applied. It says standard external reviews are decided as soon as possible, no later than 45 days after the request was received, and expedited ones as soon as possible, no later than 72 hours, or less if the medical urgency requires it.

The same page says insurers in every state must offer an external review that meets federal standards, and that your state may have a process that meets or goes beyond them. If it does, companies in your state follow the state process. If the state does not meet the federal minimum, HHS oversees a federal process. The contact for your review is on the explanation of benefits or the final internal denial. Open that line. HealthCare.gov also points to a state list kept by HHS. Use the link on that page rather than a directory you saw somewhere else.

On cost, HealthCare.gov says that if the company uses the HHS-administered federal external review process, there is no charge. If the issuer contracted with an independent review organization, or the state process applies, you may be charged, and the charge cannot be more than $25 per external review. CMS's action plan says the external review may cost up to $25, that you may need another round of internal appeals first, and that not all types of appeals are eligible. If the denial letter names a fee, quote the letter. If it does not, write FEE NOT IN THE LETTER and read the HealthCare.gov paragraph before you pay anyone.

HealthCare.gov's external-review page also lists a phone number, a fax, a mail address, and an email for people whose plan uses the HHS-administered process. Copy those from the page while you have it open, and only if your letter says that process applies. Do not put them in the chat, and do not use them for a state process that names a different office.

The No Surprises Act is a different subject. CMS's consumer page is where that law is explained, and the action plan lists the No Surprises Help Desk at 1-800-985-3059 for questions about that Act. A denied claim is not automatically a surprise bill. Do not ask the chat whether the Act cancels the denial. Read the CMS page and match it to the visit you had. The bill guide on this site walks that reading.

This is not medical, legal, or financial advice. Do not invent a deadline.

I opened HealthCare.gov and my denial. I will paste only the sentences I personally copied.

From my denial letter:
[paste the deadline sentence, or type DEADLINE NOT IN THE LETTER]

From HealthCare.gov, copied by me just now, or NONE:
[paste one sentence you copied, or NONE]

Tell me whether those two sentences name the same kind of date. If I typed NONE or DEADLINE NOT IN THE LETTER, say OPEN THE LETTER AND THE PAGE. Do not fill the blank.
Do not tell me which path to file.
Then stop.

How do you draft the appeal from the pasted facts?

One ask: please review this denial. The letter quotes the reason, states the date of service you pasted, and lists the documents you actually have. It does not accuse anyone of fraud. It does not cite a law you have not read.

The calm shape is the same as Write a polite complaint letter. You still send this one to the address on the denial, on the form the packet requires.

Draft a short appeal I can edit. This is not medical, legal, or financial advice. Do not name a statute. Do not say the denial was illegal. Do not add a dollar, a diagnosis, or a deadline I did not paste.

Who I am writing to: the appeals address on my letter. I will add it myself.
One ask: please review this denial.
Date of the letter: [date].
Date of service: [date].
Reason, quoted from my paste:
[paste only the reason]
Documents I will attach, which I already have:
[list, or NONE YET]
Deadline sentence from my letter, or DEADLINE NOT IN THE LETTER:
[paste or the label]

Rules:
- Under 200 words
- Calm
- Say I will put my name and member ID on the copy I send, not in this chat
- If a fact is not in my paste, write NOT IN MY NOTES
- No threat. No medical advice. No promise that I am right.
Then stop.

Read it aloud. Cut any sentence you would not say on the phone. Add your name, the claim number, and the member ID after the draft leaves the chat, on the copy you send. HealthCare.gov says to keep copies of what you send and of notes from phone calls, including the day, the time, and the name of the person you spoke with.

If the draft starts citing the No Surprises Act, or "ERISA," or a state insurance code, delete the citation unless you have read that source and can say, in your own words, why it matches this letter. A made-up citation makes a real question look false.

How do you prepare the phone call, then you dial?

The call is a conversation. The letter is the record. Practice out loud on Rehearse the hard conversation. The chat can play the insurer. It cannot place the call.

This is practice. This is not medical, legal, or financial advice. Do not tell me I will win.

Play the person who answers at the insurer. Use only this reason, quoted from my letter:
[paste the reason]
I will say I mailed an appeal and I am asking what document is still missing, and what date they have for my deadline.

Push back once, in a calm voice, with a question they might ask. Then stop and tell me what I still need to say in my own words.
Do not invent a deadline, a fax number, or a case number.
Do not write a script I should memorize. Give me the one question I should ask, then wait.

You dial the number printed on the denial. If a recording sends you in a circle, the written appeal is still the thing HealthCare.gov tells you to file. Do not pay a caller who offers to appeal for you by payment app.

A lab page that arrived with the claim is not the appeal. Read it, redacted, on Understand lab results with AI. That page does not diagnose. The plan you might change next year is Compare health plans with AI. An appeal does not enroll you in a new plan.

What mistakes should you avoid?

These are the misses that waste the result. Skip them before you send anything.

Common mistakes

• Pasting the insurance card so the chat has the member ID.
• Letting the chat invent a 180-day date when the letter states a different instruction, or invent a date when you have not opened HealthCare.gov.
• Sending a letter that diagnoses you or accuses the insurer of fraud.
• Treating a surprise-bill help desk as the appeals office for every denial.
• Practicing the call and then reading the script word for word. The other person will not follow it.
• Using a work or school account because it was open.
• Turning the draft in as a school assignment.

When should you not use AI for this?

Close the chat if any of these is true.

• You need a medical decision today. Call the clinician or the nurse line on your plan. If the situation is an emergency, get emergency care. This page does not triage.
• A lawyer, a lawsuit, or a state insurance department complaint is already the path you chose. Use that person or that form. The chat is not your lawyer.
• The only way to draft the letter is to paste the unredacted denial, the card, or a Social Security number. Retype the reason with the identifiers left out, or skip the chat.
• You are about to submit the chat's letter for a grade. Write the assignment yourself. Follow your teacher's rules.

What should you check before you use it?

Answer each line before you mail the appeal or pay a review fee.

Director check: look before you use it

• Are names, member IDs, and Social Security numbers still out of the chat? If one slipped in, delete that chat.
• Can you point to the denial for every date and dollar in the draft? If you cannot, take it out.
• Does the draft name a law? Keep that sentence only if you have read the page and the sentence matches.
• Is the deadline either a sentence on your letter or a sentence you copied from HealthCare.gov while the page was open? If it is neither, it does not go in the letter.
• Is there one ask? Review this denial. Not a threat, and not a new diagnosis.
• Are you treating this as advice? It is not medical, legal, or financial advice. You file the appeal. You make the call.

What is one extra tip?

Reading the bill and the explanation of benefits, before you know what was denied, stays on Understand a medical bill with AI. A lab or test page is Understand lab results with AI. Next year's coverage is Compare health plans with AI. The letter habit for a store or a repair is Write a polite complaint letter. The phone habit is Rehearse the hard conversation.

One extra tip

The moves underneath are Ask for plain English and Answer only from your sources. If the line is not on the denial or on the page you opened, the chat should say it is not there.

More plan guides are on Health plans. More money guides are on Money and bills.

Which sources back this page?

These are the public pages this guide uses. Open the one that matches the question. A sentence here is not a substitute, and it is not medical, legal, or financial advice.

• HealthCare.gov, How to appeal an insurance company decision. Internal appeal and external review, and the note that Marketplace eligibility appeals are separate.
• HealthCare.gov, Internal appeals. The 180-day filing statement, the notice clocks, the 30-day and 60-day completion clocks, and the urgent-appeal paragraph.
• HealthCare.gov, External review. The 4-month written request, which denials it describes, the 45-day and 72-hour review clocks, and the fee rule for the HHS-administered process versus a charge that cannot be more than $25.
• CMS action plan, health insurance plan denied a claim. Ask HR whether a job plan is self-funded, then the internal appeal and the external review. The No Surprises Help Desk number on that page is for No Surprises Act questions.
• CMS, medical bill rights for consumers. The No Surprises Act. It does not decide your denial.