A chronic illness advocate’s guide to a health plan denial

A practical sequence

Build an appeal record one piece at a time

1. STEP 01

   Protect the care that cannot wait

   If a delay could seriously endanger your health or ability to function, call the plan and the treating clinician promptly. Ask whether your situation qualifies for an expedited internal appeal and, where available, an expedited external review. HealthCare.gov says an expedited external review can be decided within 72 hours when its urgency standards are met. That is a review deadline, not a promise that care will be approved. HealthCare.gov urgency guidance.

   If you may be in immediate danger, seek urgent medical care. An appeal is not a substitute for care or medical advice.

2. STEP 02

   Build a clean record from the denial

   Save the denial letter, explanation of benefits, relevant plan materials, and prior approval or treatment records. Mark the date on the notice, the date you received it, the exact reason for denial, the policy or coverage provision cited, how to file, and the appeal deadline. Ask the plan for the clinical criteria and records it relied on if they are missing. For ERISA-covered group plans, the Department of Labor says you can request relevant claim documents without charge. DOL claim and appeal records.

   • Keep the notice and every attachment together; note the claim or service dates.
   • Write down each call date, the representative’s name, and any reference number.
   • Save what you submit and proof of delivery or portal confirmation.

3. STEP 03

   Explain why continuity matters in your case

   Make a short timeline of the treatment already tried, what helped or caused problems, upcoming care, and what your clinician expects could happen if treatment is delayed or changed. Attach only records that support the denial’s specific issue. For a chronic condition, ask your clinician to describe the practical effect of interruption or a switch in treatment rather than relying on the diagnosis name alone.

   “Continuity of care” can also refer to a narrower federal protection: CMS describes transitional in-network coverage for qualifying continuing-care patients when a provider leaves a plan’s network. Eligibility depends on the circumstances and coverage; that rule is not a general right to keep every denied service. CMS continuity-of-care overview.

4. STEP 04

   Ask the treating clinician for focused support

   Share the denial reason and any plan criteria with the clinician who knows your care. Ask for a concise letter that addresses the plan’s stated reason, the requested service or treatment, relevant history, prior alternatives and their results, and the clinical risk of delay or a less suitable substitute. Confirm that dates and attachments match your records. Medicare.gov also recommends asking a provider for information that may strengthen an appeal. Medicare appeal preparation.

   You can ask a trusted person to help organize papers or make calls. If someone will act as your representative, check the plan’s authorization form and the instructions for your coverage.

5. STEP 05

   File the right appeal and track every date

   Follow the address, portal, fax, or phone instructions in the denial notice. Put the deadline on a calendar with a reminder well before it, and record the date and method you filed. Deadlines are not one-size-fits-all: for example, the DOL describes at least 180 days to appeal a denial under ERISA-covered group health plans, while HealthCare.gov gives four months for an external review under its process. Your plan, state, and type of claim can change which rule applies. Read your notice and plan documents, and contact the plan or an official assistance program if the deadline is unclear. HealthCare.gov external-review deadline.

   Keep a simple log: notice date · filing deadline · clinician letter requested · appeal sent · delivery confirmed · next response due. If the plan upholds the denial, read the final notice for the next review level and its filing instructions.