Written by a parent, not a doctor. Nothing here is medical advice.

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Ask for a review when insurance says no

Every denial can be reviewed. The care team explains the medical need; some cases go to an independent outside reviewer.

What it is

Every denial can be reviewed. The care team explains the medical need; some cases go to an independent outside reviewer.

A denial letter must say why and how to appeal. Missing information, a billing error and a medical-necessity refusal need different responses, and the clinical team should answer the insurer’s stated reason. On a private plan, including a self-funded one, the internal appeal window is at least 180 days and an urgent decision comes within 72 hours; whether the dispute can then go to independent outside review depends on the plan and the dispute.

Rules
  • North Dakota Medicaid, private insurance and employer plans have different appeal steps and deadlines; the letter names the route.
  • Continuing an already-authorized service during an appeal has separate rules and deadlines; ask promptly, it is not automatic, and repayment can be a condition.
What you get
  • A second look, then an independent one, at a refusal.
  • Expedited handling when waiting could harm your child.
What it is not
  • Not a guarantee of approval.
If you decide to apply
  1. Send the denial letter to the care team’s insurance staff and confirm who submits the appeal and the deadline.
  2. Ask the team whether an expedited review is warranted and to say why.
  3. Ask right away about continuing an existing service during the appeal.

HealthCare.gov: appealing a decision · Official page ↗

Records
  • Keep the denial, the appeal, the evidence sent and every date.
Good to know

The plan-type answer from the first insurance check helps identify which outside-review route applies; the denial notice confirms it.

Other details
  • Some denials are missing-information problems. Ask whether correcting the submission and filing the appeal should proceed together; a resubmission does not by itself preserve the appeal deadline.

Related North Dakota cards: Outside review of a denial and Deadlines for treatment approvals.

Official sources
Ask your social worker

“If insurance denies part of treatment, who on the team handles the appeal, and how do we ask for the urgent version?”

Why I’m asking: We want the right evidence submitted before the deadline.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Read the denial's date and option, file the written appeal (marked urgent if treatment is waiting), and for Medicaid ask for the service to continue within 10 days.

Your social worker

Identifies the right appeal office and deadline and helps assemble the file.

The care team

Writes the letter that answers the denial's stated reason and marks it urgent when delay is unsafe.

Who decides
The plan, then an independent external reviewer or a state hearing officer
Ask the care team
“The plan denied this. Can you write a letter answering their stated reason, and can we file it as an urgent appeal so they must decide in 72 hours?”

How to apply

First step: Read the denial's date and option today. Ask the oncologist for a letter answering the stated reason, and file the written appeal marked “urgent” if treatment is waiting.

  1. Get the decision in writing with its date.
  2. Ask the clinician for a letter answering the stated reason.
  3. File marked urgent when treatment is waiting. For Medicaid ask for benefits to continue within 10 days.

Where it starts: Written appeal as the notice directs. Urgent marked as such

What to gather

  • The denial letter and envelope
  • The plan's clinical policy the denial cites
  • The clinician's letter of medical necessity answering that policy

How long: Urgent: 72 hours. A Medicaid plan appeal: 30 days. Federal external review: 45 days, or 72 hours when urgent.

Clock: File the internal appeal within 180 days of the denial (private plan).

Clock: Ask within 10 days for the service to continue during the appeal.

What a yes looks like

A written reversal or a revised approval. Confirm the start date with the provider.

What a no looks like, and the next move

The letter names the next level: external review (private plans) or a state fair hearing (Medicaid). Keep going. Each level is a new reviewer.

Watch out

  • Private plan: 180 days to file the internal appeal. 72 hours for an urgent decision. The letter names the external review option (state or federal).
  • Medicaid managed care: 60 days to appeal to the plan, decided in 30 days (72 hours expedited), then a state fair hearing. Ask for benefits to continue within 10 days of the notice.
  • A phone complaint is not an appeal. Put it in writing, keep the envelope, and get the clinician's letter answering the denial's exact reason.
  • FEHB: carrier reconsideration generally has a six-month filing window, followed by OPM review under the denial notice. Self-funded state/local plans can use an approved federal review route; it is not always HHS-administered. Use the current notice for the filing deadline.
  • Governmental-plan exemptions from some benefit rules do not create a general opt-out from applicable appeal rules. Mental-health-parity opt-outs have ended apart from a narrow qualifying collective-bargaining transition; ask the administrator to identify any claimed exception.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 10, 2026.

What it is worth

A second look at a denied drug, transplant center, nursing or scan. A decision within 72 hours when urgent. Medicaid benefits kept running during an appeal.

Legal protection: Private plan: internal appeal within 180 days of the denial. Urgent decisions within 72 hours. External review after (45 days, or 72 hours when urgent) · Medicaid managed care: 60 days to appeal to the plan. Decided within 30 days, 72 hours expedited. Then a state fair hearing · Medicaid: benefits continue when the appeal is requested within 10 days of the notice (receipt presumed 5 days after the date) · Access to the plan's rationale and clinical policy

What it costs the family: No plan appeal fee.

The eligibility facts, as published

Adverse benefit determination
yes

Decisions this site cannot make: Appeal eligibility · Medical necessity · Plan terms

Expect friction on: Deadlines on the letter · The appeal process depends on the plan type · Clinical evidence

The trap: A phone complaint is not an appeal. Put it in writing, keep the envelope, and get the clinician's letter answering the denial's exact reason.

What changes by state: The external-review option for a fully insured plan (state regulator or the federal process) and the fair-hearing period for Medicaid (60–120 days).

Where I read this

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