Appeal a health insurance denial with AI

Full guide

Getting a “denied” letter from your health insurer feels final. It usually isn't. You have a legal right to appeal, and an AI chatbot is very good at the hardest part: turning a confusing letter into a clear, organized reply. You still make the decisions and check every word.

Why bother appealing?

Very few people appeal. KFF looked at federal data for HealthCare.gov plans in 2024: insurers denied 19% of in-network claims, but people appealed fewer than 1% of those denials. Insurers upheld about two-thirds (66%) of the internal appeals that were filed, which means some did go the other way. You can't know which group you're in unless you ask.

What you need before you start

• The denial letter or Explanation of Benefits (EOB).
• Your plan's appeal instructions (often on the back of the letter or in your online account).
• Your member ID and claim number (keep these out of the chatbot; add them to the final letter yourself).
• A rough timeline: when you saw the doctor, what was ordered, what you've already tried.

Step 1: Have the AI decode the letter

Paste the letter with personal details removed and ask: “Explain why this was denied in plain English, and quote the exact reason.” Denials often come down to one of a few reasons: the plan says it isn't medically necessary, it needed prior approval, the provider was out of network, or it's treated as experimental. HealthCare.gov lists these as reasons you can appeal.

Step 2: Get your deadlines straight

Ask the AI to pull every date out of the letter. Then check them yourself. Under the federal rules HealthCare.gov describes, you have 180 days to file an internal appeal. The insurer then has 30 days to decide if you haven't had the care yet, or 60 days if you have. If your health is at serious risk, you can ask for an expedited (fast) appeal and an external review at the same time.

Step 3: Build the evidence list

The strongest appeals usually include a letter from your doctor explaining why you need this treatment. Ask the AI: “What should my doctor's letter say to answer this specific denial reason?” Then send that list to your doctor's office. It saves them time and makes it more likely they'll write it.

Step 4: Draft the appeal letter

Use the prompt on this page. A good appeal letter is short, polite and specific: it names the claim, quotes the reason for denial, answers it point by point, lists what's attached, and asks for a written decision. Tell the AI not to invent studies or policy wording. If it cites something, find it yourself before you keep it.

Step 5: Send it and keep records

Send the appeal exactly the way your plan says (portal, mail or fax). HealthCare.gov recommends keeping copies of everything and notes from every phone call: the date, time, the person's name and what they said. You can ask the AI to make you a simple call-log template.

If they still say no: external review

If the insurer upholds the denial, you can usually ask for an external review by an independent reviewer. HealthCare.gov says to file within 4 months of the final denial. Standard reviews are decided within 45 days, urgent ones within 72 hours, and the insurer must accept the reviewer's decision. It costs nothing under the federal process and no more than $25 in other processes.

Where to get free human help

Every state has a Consumer Assistance Program or Department of Insurance that can explain your rights, and HealthCare.gov says the Consumer Assistance Program can even file an appeal for you. Your doctor's billing office has also seen many denials and can tell you what usually works with your insurer.