Your denial letter has several sets of instructions on it. One paragraph talks about filing an appeal with the plan. Another mentions an independent external review. A third mentions your state insurance department. It reads as though you have three options and should pick the best one.
You do not. You have a sequence. Doing them out of order is a common way people lose an appeal they should have won, because an external reviewer will usually bounce a case that has not finished internal appeal first, and the clock does not stop while that happens.
Here is the order, and where the real leverage sits.
This is educational, not legal, medical, or insurance advice. Your denial letter and plan documents control your deadlines and your rights.
Stage one: the internal appeal
An internal appeal is you asking the insurance company to look again. The same company, but usually a reviewer who was not involved in the first decision.
People are cynical about this stage, understandably. But it is not optional, and it is not futile.
KFF's analysis of 2023 CMS marketplace data found that of 86 million denied in-network claims, consumers appealed only 376,508. Under 1%. Of those appealed, roughly 44% were overturned. That is a lot of decisions changing at a stage most people never use.
Deadline: commonly 180 days from the date on your denial letter. Your letter governs.
Response time: plans generally respond within 30 days for standard appeals and 72 hours for expedited ones.
What to send:
- A cover letter naming the member ID, claim or reference number, drug, and denial date up front
- The plan criteria, quoted, with your evidence against each line
- A prescriber letter of medical necessity on letterhead
- Supporting records: chart notes, labs, BMI history, prior medication trials with dates
- A copy of the denial letter
How to send it: in a way that produces proof. Fax confirmation, portal timestamp, or certified mail. If you call, follow up in writing the same day. Keep a log of dates, names, and reference numbers, because in a three-month process you will not remember who you spoke to on the 8th.
One thing most people skip: request, in writing, the documents the plan relied on to make its decision, including the clinical criteria and any reviewer's notes. Many plans will provide them. It is very hard to rebut criteria you have not read.
Does your plan have a second internal level?
Some plans, particularly self-funded employer plans, require two internal appeals before external review opens. Others have only one. Call and ask directly: does one internal appeal exhaust the internal process, or is there a second level? External review generally opens only after internal appeals are exhausted, so filing too early wastes weeks.
Stage two: external review
This is where the dynamic changes.
External review sends your case to an independent review organization. The reviewers are clinicians who are not employed by your plan and are not paid based on the outcome. The plan does not get to decide, and the decision is generally binding on it. That is the crucial difference from every conversation you have had up to this point.
When it is available: generally after internal appeals are exhausted. There are exceptions. If the plan failed to follow its own process or missed its deadlines, you may be able to go straight there. If waiting would seriously jeopardize your health, you may be able to run an expedited external review alongside an expedited internal appeal.
Deadline: commonly within four months of the final internal denial. This one is unforgiving. Unlike internal appeals, there is often no discretion to accept a late filing, so calendar it the day the final internal denial arrives.
What it covers: medical judgment questions. Medical necessity, appropriateness, experimental or investigational determinations. What it generally does not cover is whether a benefit exists at all. If your plan simply excludes weight management medication as a category, an external reviewer usually has nothing to decide, because the question is contractual, not clinical.
Where it goes: depends on your plan type.
- Fully insured plans usually go through your state's external review process, overseen by the state insurance department.
- Self-funded employer plans usually fall under federal rules, using an independent review organization the plan contracts with or HHS-administered review.
Ask member services one question: is my plan fully insured or self-funded? Your denial letter should also name the external review process that applies.
What to submit: usually the same file you built for the internal appeal, plus the internal denial letters. If you have anything new, this is the moment for it. A new specialist opinion, new labs, a documented failure on the alternative the plan told you to try. New evidence is more persuasive to a fresh reviewer than the same evidence stated more forcefully.
Stage three: the complaint, which runs alongside
Your state insurance department is not an appeal level. It is oversight, and it does not usually reverse a coverage decision on the merits.
What it can do is act when a plan is not following its own rules. Missed deadlines. Refusal to provide criteria. No response to a properly filed appeal. A denial letter with no appeal instructions. Those are process failures, and regulators care about them.
File the complaint in parallel if that is your situation. Do not treat it as a substitute for external review, and do not wait for it before filing. For self-funded employer plans, your state department may have limited authority and the relevant body is the federal Department of Labor. Ask when you call.
The timeline, if everything runs long
Denial. Internal appeal filed within days or weeks, decision commonly within 30 days. If your plan has a second internal level, another round. Final internal denial. External review requested within four months, with the independent decision typically taking weeks, faster if expedited.
Realistically that can be a two to four month process, which is exactly why the first internal appeal should be your strongest work rather than a placeholder. The file you send in month one is usually the file the external reviewer reads in month three.
Where to get help that costs nothing
Healthcare.gov has clear guidance on internal appeals and external review, including how the federal process works. Your state insurance department's consumer assistance line will tell you which process applies to your plan and walk you through filing. Counterforce Health offers free tools for building an appeal. If your coverage is through an employer, the benefits team can confirm plan type and whether a second internal level exists.
Every one of those is free, and a determined person with a notebook can do this alone.
The friction is not knowledge, it is assembly: the letter, the exhibit list, the deadlines, the log of who said what and when. If you would rather have that already built, our $16 GLP-1 Insurance Denial and Prior Authorization Appeal Kit includes internal appeal templates, an external review request template, and a tracking log you can start filling in tonight.
FAQ
Can I skip the internal appeal and go straight to external review?
Usually not. External review generally requires internal appeals to be exhausted first. The exceptions are when the plan failed to follow its own process, when it waives the requirement, or in urgent situations where expedited review can run in parallel. Your letter and plan documents set the rules.
How long does external review take?
Standard external review commonly takes a few weeks once the file is complete, and expedited review is much faster, often within 72 hours where health is at serious risk. The deadline to request it is tighter than the internal one, commonly four months from the final internal denial.
Is the external review decision binding on my insurance company?
Generally yes, and that is the point of it. An independent review organization decision in your favor is typically binding on the plan, which is what separates it from asking the same insurer to reconsider.
What if I miss the appeal deadline?
Ask anyway, in writing, since some plans accept a late filing for good cause. Also check whether you can start over: a new prior authorization request with better documentation produces a new decision with a new appeal window. See our guide to the first 48 hours after a denial for what to collect first.
Keep reading
- Zepbound Denied Insurance Coverage? First 48 Hours
- 7 GLP-1 Denial Reasons and Which Are Worth Appealing
Get the GLP-1 Denial Appeal Kit →
This article is general information about the insurance appeal process, not legal, medical or insurance advice. Deadlines and plan rules vary and change. Your denial letter and your plan documents govern.