How to Choose the Right Type of Insurance Appeal

Types of Insurance Appeals

Standard Internal Appeal

• Best for: Most denials where treatment is not urgent
• Timeline: Response within 30-60 days
• Use when: Medical necessity, coverage interpretation, or coding disputes

Expedited/Urgent Appeal

• Best for: Active treatment, life-threatening conditions, or discharge denials
• Timeline: Response within 72 hours (sometimes 24 hours)
• Use when: Delay would seriously jeopardize your health

External Review

• Best for: After internal appeal denial for medical necessity or experimental treatment
• Timeline: 45 days standard, 72 hours expedited
• Use when: You believe an independent reviewer would disagree with your insurer

Retrospective Appeal

• Best for: Claims denied after treatment was already received
• Timeline: Usually 60 days for decision
• Use when: Prior authorization wasn't obtained or claim was denied post-service

Formulary Exception Request

• Best for: Prescription medication denials
• Timeline: 72 hours for expedited pharmacy appeals
• Use when: Your medication isn't on your plan's formulary or is on a restricted tier

Decision Framework

1. Is it urgent? → File expedited appeal
2. Is it a medication? → Start with formulary exception
3. Was treatment already received? → Retrospective appeal
4. First denial? → Standard internal appeal
5. Already appealed internally? → External review