Insurance appeal processes
Every formal process a patient, family, or provider can use to challenge a denial. Each page shows what the process is, who can invoke it, when, and the binding deadlines.
Expedited (urgent) appeal
When standard appeal timelines would jeopardise life, health, or function. Federal law mandates 72-hour decisions for expedited appeals — much faster than standard.
External review (IRO)
Independent Review Organization (IRO) review — a binding decision by an outside organization after internal appeal is exhausted. ACA §2719 made external review available to nearly every non-grandfathered plan.
Federal IDR (No Surprises Act dispute resolution)
Federal Independent Dispute Resolution for OUT-OF-NETWORK provider payment disputes after the No Surprises Act balance-billing protections kick in. 'Baseball arbitration' between provider and payer.
Grievance (vs appeal)
A grievance is a complaint about plan conduct — service, access, quality — that does NOT involve a coverage decision. Distinct from an appeal, with its own track and timelines.
Internal appeal
The first level of appeal after a denial — review BY THE PLAN of its own decision. The mandatory first step before external review or court.
Peer-to-peer (P2P) review
A live phone conversation between the prescribing physician and a plan medical director or pharmacy reviewer. Often overturns a denial in 15 minutes when the physician explains the clinical context.
Retrospective (retro) authorization
Authorization requested AFTER a service was rendered — typically for emergency, urgent, or out-of-network care that couldn't wait for pre-auth. Many plans have a formal retro-auth process; some require provider appeal instead.
State Fair Hearing (Medicaid)
After exhausting Medicaid MCO internal appeal, beneficiaries have the right to an Administrative Law Judge hearing at the state Medicaid agency. The state hearing officer can overrule the MCO.
Contact: hello@denialhelp.com