Fighting a health insurance denial? Here are some tips to help.

When Sally Nix found out her health insurance company wouldn’t pay for an expensive, doctor-recommended treatment to ease her neurological pain, she prepared for battle.

It took years, a chain of conflicting decisions and a health insurer switch before she finally won approval. She started treatment in January and now channels her time and energy into helping other patients fight denials.

“One of the things I tell people when they come to me is: ‘Don’t panic. This isn’t a final no,’” Nix, 55, of Statesville, North Carolina, said.

To control costs, nearly all health insurers use a system called prior authorization, which requires patients or their providers to seek approval before they can get certain procedures, tests and prescriptions.

Denials can be appealed, but nearly half of insured adults who received a prior authorization denial in the past two years reported the appeals process was either somewhat or very difficult, according to a July poll by KFF, a health information nonprofit that includes KFF Health News.

“It’s overwhelming by design,” because insurers know confusion and fatigue cause people to give up, Nix said. “That’s exactly what they want you to do.”

Here are tips to consider when faced with a prior authorization denial.

Know your insurance plan

Do you have insurance through your job? A plan purchased through healthcare.gov? Medicare? Medicaid?

Different categories of health insurance are governed by different agencies and are therefore subject to different prior authorization rules.

Federal marketplace plans, as well as Medicare and Medicare Advantage plans, are regulated by the U.S. Department of Health and Human Services. Employer-sponsored plans are regulated by the Department of Labor. Medicaid plans, administered by state agencies, are subject to both state and federal rules.

Learn the language specific to your policy. Health insurance companies don't apply prior authorization requirements uniformly across all plans. Read your policy closely to make sure your insurer is following its own rules, as well as regulations set by the state and federal government.

Work with your provider to appeal

Kathleen Lavanchy spent much of her career communicating with health insurance companies on behalf of patients, before retiring in 2014.

Lavanchy said before you contact your insurer, call your provider and ask to speak to a medical care manager or someone in the office who handles prior authorization appeals.

You or your provider can request a “peer-to-peer” review during the appeals process, which allows your doctor to discuss your case over the phone with a medical professional who works for the insurance company.

Be organized

Many hospitals and doctors use a system called MyChart to organize medical records and patient communications. Similarly, patients should keep track of all materials related to an insurance appeal — records of phone calls, emails, letters and in-app messages.

“Keep an amazing paper trail,” Nix said. “Every call, every letter, every name.”

Linda Jorgensen, executive director of the nonprofit Special Needs Resource Project, has advised patients who are fighting a denial to keep paper copies of everything.

“If it isn’t on paper, it didn’t happen,” she said.

Jorgensen, who serves as a caregiver to an adult daughter with special needs, created a free form you can print to help guide you when taking notes during phone calls with your insurance company. She advised asking the insurance representative for a “ticket number” and their name, before proceeding with the conversation.

Appeal as soon as possible

The silver lining is that most denials, if appealed, are overturned.

Medicare Advantage data published by KFF in January found nearly 82% of prior authorization denials from 2019 through 2023 were partially or fully overturned upon appeal.

But most health plans give you only six months to appeal, according to rules laid out in the Affordable Care Act.

“Don’t dillydally,” Jorgensen advised, especially if you’re sending a paper appeal, or any supporting documents, through the U.S. Postal Service. She recommends filing quickly and at least four weeks before the deadline.

Ask for help

If you get your health insurance through an employer, there’s a good chance your health plan is self-funded or self-insured. That means your employer contracts with a health insurance company to administer benefits, but your employer shoulders the cost of your care.

Under self-funded plans, decisions about what is or isn’t covered rest with your employer.

For example, your doctor has recommended you undergo surgery and your insurer has denied prior authorization, deeming the procedure not medically necessary. If your plan is self-funded, you can appeal to the HR department at your job because your employer is on the hook for your health care costs — not the insurer.

Many states operate free consumer assistance programs, which can help you file an appeal. They can explain your benefits and may intervene if your insurance company isn’t complying with requirements.

There's also nonprofit advocacy groups, such as the Patient Advocate Foundation, that can help.

Sometimes, when patients and doctors shame insurers online, denials get overturned.

The same holds when patients contact lawmakers. State laws regulate some categories of health insurance, and when it comes to setting policy, lawmakers have the power to hold insurance companies accountable. It isn’t guaranteed to work, but it might be worth a shot.