Getting a denial letter from your health insurance company can feel like hitting a wall — especially when you or a family member actually needs the care. The good news is that denials get overturned all the time. The appeals process exists specifically to give you a real shot at reversing that decision, and Florida law gives you meaningful protections along the way.
This guide walks you through the full appeals process step by step, from the moment you get denied to what happens if the external review doesn't go your way.
Step 1 — Read the Denial Letter Carefully
Your insurer is required to send you a written notice explaining why the claim or service was denied. Before you do anything else, read it carefully and look for:
- The specific reason for denial (e.g., "not medically necessary," "not a covered benefit," "prior authorization required")
- The deadline to file an internal appeal
- Contact information for the appeals department
- Whether you have the right to external review
The denial reason matters because it shapes your appeal strategy. A "not medically necessary" denial requires different documentation than a "not a covered benefit" denial.
Step 2 — File Your Internal Appeal
Before you can request an external review, you must go through your insurer's internal appeal process first. Under ACA rules, you have at least 180 days from receiving the denial to submit your internal appeal. Don't wait — gather your documentation and file promptly.
What to Include in Your Appeal
- A written letter stating that you are appealing and why you believe the denial was incorrect
- A letter from your doctor explaining why the service is medically necessary
- Relevant medical records, lab results, or imaging that support your case
- Clinical guidelines or peer-reviewed studies that support the treatment (if available)
- A copy of your EOB (Explanation of Benefits) and the original denial notice
Submit your appeal in writing — certified mail or through the insurer's secure portal — and keep copies of everything. If you call the carrier, follow up the call with a written summary of what was discussed. A paper trail matters if you proceed to external review or legal action.
Internal Appeal Timelines
| Type of Appeal | Insurer Must Respond Within |
|---|---|
| Standard internal appeal (post-service claim) | 60 days |
| Standard internal appeal (pre-service / prior auth) | 30 days |
| Expedited internal appeal (urgent care) | 72 hours |
| Concurrent care denial | Before the reduction takes effect |
Step 3 — Request Expedited Review if Urgent
If waiting for the standard appeal timeline would seriously jeopardize your health, your life, or your ability to regain maximum function, you have the right to request an expedited appeal. The carrier must respond within 72 hours.
Expedited review applies to situations like ongoing cancer treatment, a hospital discharge that needs to be delayed, or a medication your doctor says cannot be interrupted. Your doctor can support the expedited request by documenting the clinical urgency.
If you're in the hospital or facing an urgent situation, call the insurer's appeals line immediately and explicitly state you are requesting expedited review. You can submit your documentation simultaneously with the request — don't let them delay processing by waiting for a complete file.
Step 4 — External Review Through an Independent IRO
If your internal appeal is denied — or if 60 days have passed without a decision — you have the right to request an external review by an Independent Review Organization (IRO). This is one of the most important consumer protections in the ACA.
An IRO is an independent third party, certified and assigned by Florida's Office of Insurance Regulation (FLOIR), that reviews your case without any financial relationship with your insurer. If the IRO rules in your favor, the insurance company is legally bound to follow that decision.
Florida External Review Process
- You generally have 4 months after final internal denial to request external review
- File your request with your insurer or directly through FLOIR
- The IRO must make a decision within 45 days for standard reviews, 72 hours for expedited
- There is no filing fee for external review in Florida for most plan types
Under the ACA, all non-grandfathered health plans — including most marketplace plans, employer group plans, and individual plans — must offer external review. Self-funded employer plans (ERISA plans) follow federal external review standards. If you're unsure which rules apply to your plan, call FLOIR at (850) 413-3140.
What to Do If You Lose the External Appeal
An IRO decision against you isn't always the end. You still have options:
- File a complaint with FLOIR — if you believe the insurer violated state law or your plan terms
- Contact a patient advocate — nonprofit patient advocacy organizations can sometimes negotiate directly with carriers
- Pursue legal action — you can sue your insurer in state or federal court; an attorney who specializes in insurance bad faith can evaluate your case
- Contact the CMS Marketplace appeals process — if you're on a marketplace plan and the issue involves plan compliance, a separate federal appeals channel exists
Working with the right health insurance plan from the start can minimize the risk of coverage disputes. Florida Plan Finder helps you compare plans across Florida so you understand network, cost-sharing, and covered benefits before you enroll. If you want personalized help evaluating your current coverage or shopping for a plan with fewer coverage gaps, the licensed brokers at Get Florida Coverage can help — at no cost to you.