Questions, answered plainly

Your denial letter or EOB (Explanation of Benefits, the statement your plan sends) gives a reason, often as a code. Among in-network claims denied by HealthCare.gov insurers in 2023, the reasons were:

• Other or not stated: 34%
• Administrative: 21%
• A service the plan excludes: 14%
• No prior authorization or referral: 9%
• Not medically necessary: 6%

Source: KFF, claims denials in ACA marketplace plans, 2023. The free decoder reads the reason on your own letter and explains it.

Most plans use standard codes. A CARC (claim adjustment reason code) says why the plan paid differently than the bill. A RARC (remark code) adds detail. For example, CARC 50 means the plan did not consider the service medically necessary.

The decoder translates every code it finds on your letter.

Code list: X12 claim adjustment reason codes

It depends on your plan type:

• Individual, marketplace and fully insured employer plans: 180 days to file an internal appeal. HealthCare.gov
• Self-funded employer plans (ERISA): at least 180 days. 29 CFR 2560.503-1
• Medicare Advantage: 65 days to ask the plan to reconsider. CMS
• Medicaid managed care: 60 days to appeal to the plan. 42 CFR 438.402(c)(2)(ii)

Your plan documents can give you more time, never less. The decoder works out your date from the date on your letter.

An internal appeal asks your plan to look at its decision again. If the plan still says no, an external review lets an independent reviewer decide.

For plans under the ACA rules, you ask for external review within 4 months of the plan's final denial. The reviewer decides within 45 days, or within 72 hours if the review is expedited (urgent). The decision is binding on the plan.

Source: CMS, external appeals

Appeals are rare. Fewer than 1% of denied ACA marketplace claims were appealed in 2023. A real share of the denials that are appealed get overturned, but the rate varies widely by market and year, and no one can tell you how your plan will decide.

If you are unsure, a free state consumer assistance program can talk it through with you.

Sources: KFF, 2023 plan data; KFF, prior authorization, 2026

Ask for your claim file and the criteria the plan used to deny the claim. If you have a self-funded employer plan, you have a right to free copies of the documents relevant to your claim.

The appeal case includes a request letter for this.

Rule: 29 CFR 2560.503-1(h)(2)(iii). Read the rule

For a "not medically necessary" denial, a letter from your doctor is usually a key part of the evidence. Only your doctor can say a treatment is medically necessary. We draft the request letter you send to your doctor; we never recommend a treatment.

If waiting could seriously harm your health, call your plan now, ask for an urgent (expedited) review, and talk to your doctor. An expedited external review is decided within 72 hours.

Our packet is built for appeals that can take days or weeks to prepare, not for emergencies. If this is a medical emergency, call 911.

Not to decode a letter. You need an account to start a case, so your documents and deadlines are saved. You sign in with your email and a 6-digit code we send you. There is no password.

Your denial letter, your EOB, an itemized bill if you want the bill audit, and your plan documents if you have them. A PDF or a clear photo from your phone both work.

We tell you what we could not read. You can try a clearer photo, or type in the key details yourself: the date, the claim number and the reason. You check everything we read before anything is built on it.

No. You send it. We prepare one PDF and show you where to send it for UnitedHealthcare, Aetna and Cigna. For other plans, use the address or form named in your denial letter.

We do not mail, fax, call or write to your plan for you, and we are not your representative.

Yes, every sentence. Details we filled in from your documents are marked so you can check them, and we point out anything still missing before you download.

We use software, including AI models, to read your documents and draft text. Your route and deadlines come from a fixed set of published rules, each with its source, not from an AI guess.

Software can make mistakes, so we show you what we read and you review every word before you send anything.

When you save a result from the decoder, you can turn on email reminders for 30, 14 and 3 days before each deadline. They are off until you choose them. You can also download a calendar file (.ics) and add the dates to your own calendar. Both are free with any saved result. If a deadline falls on a weekend or holiday, we tell you to send by the business day before.

Reminders keep your email address and deadline dates, encrypted, and nothing else. They stay after your 24-hour decoder result is deleted, and are deleted when the deadline passes. When you turn them on we give you a turn-off link: open it any time to turn them off and delete your email address. Deleting your account also deletes the reminders sent to its email address.

The denial decoder is free. An appeal case is $49 one time. An appeal case with the bill audit is $79 one time. You can add the bill audit to an appeal case later for $30.

Full pricing

After you have confirmed your plan type and deadline, and before the evidence checklist and letters. You always see your route and deadline first.

Neither. You pay once per case. If your plan pays or a bill comes down, all of that money stays with you.

You get a full refund if the packet is incomplete for your plan type, or if a deadline we worked out is wrong. A refund never depends on whether your plan says yes or no.

You can. The service providers that read documents and draft text for us process them only to do that job, under terms we are choosing so they keep no copy (to confirm before launch). We do not sell your documents or share them for advertising.

No. There are no third-party pixels or ad trackers on any page that sees your health information, and we never share it for advertising.

Files in a case are deleted 30 days after you close the case. You can delete them sooner at any time.

If you use the decoder and do not save the result to a case, we delete the upload 24 hours after you upload it.

One button deletes a case, or your whole account, right away. You find it in your account settings.

Delete my data

Usually not, and we will not claim otherwise. HIPAA, the federal health privacy law, applies to health plans, most doctors and hospitals, and the companies that work for them. A tool you choose to use yourself is usually none of those.

What protects you instead: we ask for your consent before we use your health information, using Washington state's My Health My Data standard for everyone. We follow the FTC Health Breach Notification Rule. We use no ad pixels, and we delete on a timer.

Source: HHS, who HIPAA covers. Read the privacy policy

No. AppealHaven is a document-preparation and information tool. It is not a law firm, it is not your lawyer or representative, and it is not a substitute for a lawyer.

You may want a lawyer if your case goes to court, for example a lawsuit against a self-funded employer plan after the appeals are done. Legal aid offices help people with low incomes for free.

No. We never recommend a treatment. Only your doctor can say a treatment is medically necessary; we draft the request for your doctor's letter.

No. Your plan, or an independent reviewer, makes the decision. No one can honestly promise an outcome, and we do not.

We work out deadlines from published federal rules and the date on your letter. Your plan documents can give you more time. If they show a different date, change it in your case and confirm it with your plan. If you are not sure, aim for the earlier date.

For fully insured plans, state insurance rules also apply and can add rights. We work from the federal rules. Many states run a free consumer assistance program for employer and marketplace plans; if yours does, it knows your state's rules.

Yes, for free: the decoder explains your letter and your deadline, and points you to free help. We do not prepare paid packets for Medicare.

• Medicare Advantage: 65 days to ask the plan to reconsider. If the plan still says no, the case goes to an Independent Review Entity automatically. CMS
• Original Medicare: five appeal levels. The first, a redetermination, must be asked for within 120 days. CMS

Your SHIP counselor helps with Medicare appeals for free.

The decoder is free for Medicaid letters too. With a Medicaid managed care plan, you have 60 days to appeal to the plan, and the plan decides within 30 days. After that you can ask for a state fair hearing; your state gives you 90 to 120 days from the plan’s decision letter.

If your state pays your doctors directly, with no managed care plan, there is no plan appeal. You ask your state for a fair hearing, by the date on your notice. States allow up to 90 days, and some allow less.

Your state Medicaid office and legal aid can help for free.

Rules: 42 CFR 438.402(c)(2)(ii), 438.408(f)(2) and 431.221(d)

Medicare and Medicaid each have their own appeal systems, and free counselors already know them well. We started with employer and individual plans, whose rules we have built and checked.