Appeals, Grievances, Coverage Cancellations & Insurance Denials
If your health insurance was cancelled, your claim was denied, your treatment was refused, or Covered California made a decision you believe is wrong, the next step depends on the type of problem and the type of coverage you have.
Coverage Cancelled?
Start here if your policy was cancelled or terminated because of missed premiums, grace period problems, auto-pay failure, or a billing issue.
- Grace period issues
- Never received a bill
- Auto-pay failed
- Reinstatement requests
- New coverage after termination
Treatment or Claim Denied?
Start here if the insurance company denied a procedure, referral, medication, hospital stay, or claim payment.
- Medical necessity denial
- Prior authorization denial
- Prescription drug denial
- Out-of-network dispute
- Independent Medical Review IMR
Covered California Issue?
Start here if the problem involves Covered California eligibility, subsidy amounts, enrollment, residency, income, or Special Enrollment.
- Eligibility dispute
- Premium tax credit problem
- Enrollment error
- Special Enrollment issue
- Application problem
Coverage Cancelled for Non-Payment, Grace Period, or Billing Problem?
If your health insurance was cancelled for non-payment, do not assume the answer is final. The next step depends on why the premium was not credited, whether you were still within a grace period, whether notices were sent correctly, and whether the insurance company, Covered California, or the payment system made an error.
Common cancellation problems
- Missed premium payment: The carrier says the premium was not paid by the due date.
- Grace period expired: The policy was terminated after the grace period ended.
- Auto-pay failed: A bank account, credit card, carrier portal, or payment system did not process the payment.
- Never received the bill: You may need notices, emails, portal messages, mailing records, or USPS Informed Delivery records.
- Payment was made but not applied: You may need bank or credit card proof, confirmation numbers, and carrier payment history.
- Need new coverage: If reinstatement is not available, review Special Enrollment options quickly.
What to gather before asking for help
- Cancellation or termination notice
- Premium bills and due dates
- Proof of payment from your bank or credit card
- Auto-pay confirmation or failure notice
- Covered California notices, if applicable
- Carrier portal screenshots
- Any emails, letters, texts, or phone notes
Possible next steps
- Ask the carrier whether reinstatement is available.
- File a grievance or appeal if you believe the cancellation was wrong.
- Check whether Covered California needs to correct eligibility or enrollment records.
- Review whether a Special Enrollment Period is available if the old policy cannot be restored.
- Keep a written timeline of every call, payment, notice, and response.
A cancellation problem may be a carrier billing issue, a Covered California issue, a bank/payment issue, or a Special Enrollment issue. The facts matter. The goal is to determine whether the coverage can be reinstated, whether an appeal or grievance makes sense, or whether you need to move quickly to replace the coverage.
Introduction
The process of appeals & grievances gets very technical, legal, etc. I won’t even attempt to summarize it here. Please follow the links below, guides & summaries to the right, check your policy – evidence of coverage and check the law.
Medical Procedures?
- Was your procedure Medically Necessary?
- Los Angeles Medical Necessity Denials Lawyer
- Los Angeles Health Insurance Lawyers
- Independent Medical Review IMR
- Did you use the Correct MD or hospital – Provider List and
- Did you Review the procedures in your actual policy, evidence of coverage?
Reasons why the Claim might be denied
- Did you tell the truth on your application?
- Nearly 15% of claims submitted to private payers are initially denied
- Insurers’ denial rates — a critical measure of how reliably they pay for customers’ care — remain mostly secret to the public. Federal and state regulators have done little to change that.
- Claims Denials and Appeals in ACA Marketplace Plans in 2021 kff.org
- Wrestling With a Giant: How to Dispute a Hospital Bill
- Here’s where they write to your MD, prior to ACA/Obamcare before a claim is even turned in.
- How about doing a pros & cons spreadsheet – Ben Franklin method? It’s important to know the other sides point of view and potential arguments & evidence.
- Billing Codes – Satire or how it really works?
- Was the policy in force? Lapse non pay?
- Department of Labor on Filing a Health Claim dol.gov pdf
- View as a webpage dol.gov
- Most U.S. adults don’t know they can fight insurance denials, new study finds
Insurance Company & Regulatory Agency
Grievance Procedures & Forms
- Check your EOC – Evidence of Coverage for procedures & where to get forms.
- Aetna
- Blue Cross Grievance Procedures
- Notice
- Blue Shield – General Info. Appeals & Grievances PO Box 629007 El Dorado Hills , CA 95762 – 9007 Fax: (916) 350 – 7585
- CA Department of Insurance
- IMR – Independent Medical Review
- REQUEST FOR REVIEW Molina Health Care OF CANCELLATION, RECISSION, OR NONRENEWAL OF HEALTH CARE SERVICE PLAN BENEFITS
- hhs.gov/curbing-insurance-cancellations
- DGS Office of Administrative Hearings
- Kaiser Member Grievance Form
- #Appeal Guides
- Navigating the Appeals Process –Patient Advocate Foundation
- NAIC Sample Appeals letter & process
- VIDEO Clark Howard – How to appeal
- LA Times appeal explanation 1.19.2022
- Kantor & Kantor Attorneys VIDEO
- courts.ca.gov/selfhelp-smallclaims
- California Small Claims – Court Site – Self Help
- Fillable Forms
- Small Claims Adviser Los Angeles 213.974.9759
- If you have a claim for more than the Small Claims Limit, you can sue, but you waive the amount over the limit.
- Flyer
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Small Claim Court Study Guide for temporary – pro tem judges – highly likely you might have an attorney whose volunteering to be a Judge for the day.
- Small Claims Court Procedures & Practices – including training for judges
- Judges Bench Guide for cases involving self represented litigants
- REACHINGOUT OR OVERREACHING Judicial Ethics and Self-Represented Litigants
Department of Consumer Affairs – Mediation Request ONLINE
How Mediation Works & Paper Mediation Request Form
- Fair Shake.com Arbitration – They will send a demand letter!
Appeals? Grievances?
Check the FULL policy, EOC – Evidence of Coverage Also, here’s a guide in how to read and interpret contracts. that’s what an Insurance Policy is.
Then if you do decide to do an appeal, (page 151 in specimen policy) or view our webpage on appeals, you’ll know what to argue about.
See our main webpage on appeals & grievances
Consumer Links & Resources
- How to gather documents to prove your case – Small Claims Manual
- Prove you never got a letter?
- How to tell your story, timeline and background
- How to create a TIMELINE in Word, Excel, PowerPoint
- Health Net faces suit over refusal to cover treatments LA Times 9.13.2012
- Appeal Guide – Washington State Department of Insurance 62 pages pdf
- Nolo – Medical Malpractice Basics
- Todd Friedman, Esq. can help if debt collectors are harassing you when you don’t owe the $$$
- Find an Attorney
- Health Consumer Alliance HCA
Part of Department of Managed Health Care - Patient Advocate.org
- Health Consumer Alliance
- Center for Health Care Rights
- National Association of Health Care Advocacy
- California Health Consumer Advocacy Coalition
- CA Health Care Advocates
- HICAP
- Legal Brief Blue Shield allegations about Narrow Networks
- Los Angeles Times how to fight back
- Register an account with CDSS
Covered CA Appeals
#Reasons for filing a Covered CA appeal
Your eligibility notice explains what you are eligible for and the programs for which you do not qualify. Depending on your eligibility results, you may appeal any of the following (check as many boxes as you would like):
- I was denied enrollment into a Covered California health plan
- The amount of Premium Assistance (tax credits that help pay my monthly premium) is not correct – Get Calculation
- The level of Cost Sharing Reduction (help paying my out of pocket expenses) is not correct
- I was denied eligibility for an exemption from the individual responsibility CA Mandate Penalty
- Covered California did not process my information in a timely manner
- Covered California stated that I am not a US Citizen or US National or a lawfully present individual living in the United States
- Covered California stated that my application was incomplete
- I do not have other health coverage (such as free Medi-Cal or employer sponsored insurance) that prevents me from qualifying for insurance through Covered California
- Covered California stated that I am not a California Resident
- Covered California stated that I did not pay my premiums by my due date
- Covered California stated that my MAGI income is too low chart to qualify for Covered California coverage Get Calculation
- Other Tell us more about why you disagree with Covered California’s decision. You may attach additional sheets of paper if you need more space to write. Covered CA Appeals Request Form *
We STRONGLY suggest you attach additional sheets of paper and explain your case, with citations, evidence & exhibits. Be sure to read all the helpful aids we have on this page. You are going up against well versed opponents!
Resources & Links
Cover Page for Covered CA’s Brief to the Administrative Law Court
- CDSS State Hearings Division’s Decision Registry – Read prior cases – names are redacted
Covered CA Appeals Decision #Polk Case
- Sample Letter for Appeal
- Explanation on Insure Me Kevin . com - Polk Case
- Check out where administrative law judge said he wished he could make Covered CA pay the costs of their bogus advise but didn't have that authority
- Doesn't matter what Covered CA says, it's what the IRS says Form 8962 attaches to Form 1040
Medicare Appeals
How to file #Medicare appeals, deal with issues, claims, problems, etc.
- Medicare Appeals can get complex, so we won’t really try to summarize it. Please review the brochures, information and links below and on your right. Appeals are a complex subject we are giving you mostly official guides and not our summary, advise or essays.
- Medicare Complaint Form on Medicare.Gov
- See also Fillable pdf 10287 pdf
- How to file a complaint – Medicare.Gov
- Medicare Advantage – Livanta
- Medicare Appeals Publication # 11525 60 pages
- File complaint against Medicare itself?
- Medicare Contact Info * More * Forms *
- HICAP CA * Rest of USA * (Health Insurance Counseling and Advocacy Program)
- National Center on Law & Elder Rights – Case Consultation for Professionals
- Sample Evidence of Coverage – Medicare Advantage
- This is NOT sales literature, but is provided as a public service for educational purposes.
More on Medicare Appeals
- Livanta ONLINE Appeal System
- AHA wants False Claims Act enforcement of Medicare Advantage care denials Modern Health Care 5.20.2022 See also Beckers Hospital Review
- False Claims Act – Whistle Blower.com
Filing an appeal with Medicare
- Official Medicare Advantage Plan Appeals VIDEO
- How to Appeal a Denial of your Health Claim – VIDEO Kantor & Kantor Attorneys
- Medicare Appeals Fact Sheet – CA Health Care Advocates Hi Cap
- See our other page on appeals
- the exact proper terms.
- Grievance—A complaint about the way your Medicare health plan or Medicare drug plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you’re unhappy with the way a staff person at the plan has behaved towards you. However, if you have a complaint about a plan’s refusal to cover a service, supply, or prescription, you file an appeal.
- Appeal—An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan. You can appeal if Medicare or your plan denies one of these:
■ Your request for a health care service, supply, item, or prescription drug that you think you should be able to get
■ Your request for payment for a health care service, supply, item, or prescription drug you already got
■ Your request to change the amount you must pay for a health care service, supply, item or prescription drug
You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need. - medicare.gov/Appeals.pdf
- Will see how my Appeal for a TKR now goes, since I’ve met the qualifications of “conservative treatments” over the course of the last 2-3 years!!!
- Please when using technical terms, define them and provide a URL.
/cgsmedicare.com/
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Medicare Billings And Claims
- G-001-Organizing Your Medical Bills – 07-19-12
- G-002-How Medicare Claims Are Processed – 07-19-12
- G-003-Instructions For Creating a Claims Record – 07-19-12
- See our webpage on
- Medicare Appeals & Grievances
- Fraud
- Attorneys – We don’t know them… Found on Google
- Medicare Appeals & Grievances
-
Medicare Technical & Research Links
- Medicare Claims Processing Manual Technical 319 Pages
- Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Effective August 3, 2022 Table of Contents
- One hour webinar by an attorney, on how to do claims & appeals – You Tube
- 42 CFR Part 422, Subpart M – Grievances, Organization Determinations and Appeals
Find an Attorney
- Legal Match
- Findlaw.com
- American Bar Association
- Attorney Search Network
- Follow the links on this webpage. Many of them go to articles on Attorney Websites
- Also, see our appeals webpage
- Medi Cal Contact
- State Bar of California.com Attorney Referral Service
#Attorney 's --- Social Security Disability maze
- Sellers Law
- Hill & Ponton
- premier disability.com
- Cantrell & Green
-
- We don't necessarily know these attorney's...
- Editorial: Lawyers are fighting innovative proposals for more affordable legal assistance. That’s wrong LA Times 1.30.2022
Estate Planning
- We don't necessarily know these attorney's...
Customer Service – Enforcement
Dealing with Customer Service Issues
- First and foremost, be polite.
- These are crazy days as well for service reps, nearly all of whom aren’t to blame for their companies’ penny-pinching practices.
- A little civility goes a long way.
- Don’t be shy about escalating.
- Front-line service reps are frequently not given the power to resolve matters on their own and will often give an unsatisfactory response. Ask to speak with a supervisor.
- If that doesn’t work, write to the company’s chief executive or president, detailing the nature of the problem and providing as much documentation as possible. Most big companies have special dispute-resolution departments at senior levels.
- Be persistent. If it becomes clear that you’re not going away, some companies will finally throw in the towel and offer the response you’re seeking. Squeaky wheels and all that. LA Times 8.8.2020 *
#SNAFU - Situation Normal - All Fouled Up
I learned the word SNAFU Situation Normal, All Fouled Up in the dorm, when I attended San Diego State in the early 70's and earned a degree in Insurance. In all that time, I've never been able to use the word in a sentence, until last 10.1.2013, when Covered CA.com, Health Care.Gov nor the Insurance Company Websites or my own Quote Engine that I pay around $250/month for were supposed to launch, but did not do it properly.
Steve - when he's not updating the website outside of Open Enrollment
Technical Stuff for Attorneys
Appeals Law
Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the Patient Protection and Affordable Care Act
- June 22, 2011 CMS-9993-IFC2: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes – Opens in a new window
- July 26, 2011 CMS-9993-CN: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes; Correction – Opens in a new window (PDF – 184 KB)
From CMS Site
- Regulations & Guidance
- Fact Sheets & FAQs
- Letters & News Releases
- State External Appeals Review Processes
Resources, Child Pages & Links
- Insure Me Kevin.com
- Patient Advocate.org
- Prove you never got a letter?
- Medical Necessity Grievances
- Appeal & Grievances?
Technical Links – Appeals & Grievances
- Page 19 Section §2719 of Health Care Reform -Appeals Process
- 45 CFR Part 147 Interim Final Rules for Group Health Plans and Health Insurance Issuers – Appeals
- § 147.136 — Internal claims and appeals and external review processes.
- 7/26/2011 – Final Rules – EBSA – Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes; Correction [PDF]
See also Medical Necessity
California Insurance Code §790.03 (h) Knowingly committing or performing with such frequency as to indicate a general business practice any of the following unfair claims settlement practices: Calif. Code of Regulations TITLE 10. CHAPTER 5 ADOPT SUBCHAPTER 7.5 with new 2004 amendments on CA Department of Insurance Site
https://www.commonwealthfund.org/publications/surveys/2026/jun/how-health-insurance-coverage-denials-affect-americans-2025-affordability-survey
Very informative read. The breakdown helped me a lot..
https://www.beckershospitalreview.com/finance/13-top-reasons-for-claims-denials/
wmar2news.com/local/maryland-recovers-2-6-million-for-consumers-fighting-denied-health-insurance-claims#google_vignette
Yeah!!!! You did it!!! I’m so thankful!!!
You are not superman but SuperSteve!!!!!
You have done the impossible!!!
I know I know, I shouldn’t be celebrating until I get the insurance. Even coming this far was impossible for me. Without your help, I would have just accept their decision and gone without insurance for a year. I either would have used our savings to pay for surgery or have to wait until next year while suffer the consequences.
I couldn’t thank you enough. I’m so grateful to you.
Thank you for the Kudo’s.
Here’s the Draft Appeals Brief had we needed to actually go before the Judge. All your personal information has been redacted