Appeals We Handle

What We Do

We believe a denial letter should not be the end of your care. Appeal Healthcare represents patients and families in Kentucky and Ohio who have been denied health insurance coverage for medically necessary treatment. We focus on healthcare denial appeals, whether the denial involves a private employer plan governed by the Employee Retirement Income Security Act (ERISA) or other coverage governed by federal and state rules, such as an Affordable Care Act (ACA) Marketplace plan, Medicare Advantage (Part C), Medicaid managed care, or an individual policy.

We guide you through the appeal process with plan analysis, organization of medical evidence, and deadline-driven execution. We aim to submit a complete, evidence-backed appeal that responds directly to every reason the insurer gave for the denial and puts you in the strongest position to pursue covered benefits.

Understanding Employee Retirement Income Security Act (ERISA) and Plans Not Governed by Employee Retirement Income Security Act (ERISA)

Health insurance denials usually follow one of two paths: plans governed by the Employee Retirement Income Security Act (ERISA) and plans not governed by the Employee Retirement Income Security Act (ERISA). Identifying your plan type matters because the rules, deadlines, and next steps can differ. A misstep can limit your options later.

Employee Retirement Income Security Act (ERISA) Appeals

Many private employer-sponsored health plans are governed by the Employee Retirement Income Security Act (ERISA). These appeals are procedural and deadline-sensitive. A strong Employee Retirement Income Security Act (ERISA) appeal often requires:

• Completing the plan’s internal appeal process (sometimes called exhaustion of remedies).
• Building a thorough administrative record (the file that may matter most if the case later goes to court).
• Interpreting plan terms, exclusions, and coverage standards under the Employee Retirement Income Security Act (ERISA).

We build Employee Retirement Income Security Act (ERISA) appeals by tying the medical record to the plan language the insurer relied on, addressing each stated reason for denial, and presenting your position in an organized, submission-ready format.

Appeals for Plans Not Governed by Employee Retirement Income Security Act (ERISA)

Plans not governed by the Employee Retirement Income Security Act (ERISA) can include:

• Affordable Care Act (ACA) Marketplace policies
• Medicare Advantage (Part C) plans
• Government employee plans
• Church or association-based coverage
• Medicaid managed care plans

These appeals may be governed by state law, federal regulations, and plan-specific rules. Some denials allow external review by an Independent Review Organization (IRO). Others follow different agency or plan procedures. Deadlines vary, but delay can reduce available options.

We tailor the appeal to the controlling framework, follow the proper process, and pursue each available review stage when applicable.

Step by Step: How the Appeal Process Works

Step 1: Review, plan type, and deadlines

We review your denial letter, identify your plan type, confirm the appeal deadline, and determine whether expedited review may apply.

Step 2: Strategy and document collection

We gather and organize the materials that support a strong appeal, such as:

• Medical records
• Treating-provider letters and support
• Explanation of Benefits (EOB)
• Plan documents and relevant coverage terms
• Provider notes and treatment timeline
• Claim and denial documentation from the insurer, when available

Step 3: Internal appeal submission

We prepare and submit a structured appeal that responds to each stated denial reason using medical evidence and the plan’s terms. For Employee Retirement Income Security Act (ERISA) plans, we emphasize record-building and completeness.

Step 4: Monitoring and follow-through

We track the appeal and respond to information requests. We push for timely handling and protect your appeal rights at each stage.

Step 5: Next steps after an internal denial

If the appeal is denied again, next steps depend on the plan type:

• For many plans not governed by the Employee Retirement Income Security Act (ERISA), we assist with external review by an Independent Review Organization (IRO) when available.
• For Employee Retirement Income Security Act (ERISA) plans, we evaluate whether litigation under 29 U.S.C. § 1132(a) is an appropriate next step, based on the plan language, the record, and the applicable standard of review. In many benefits cases under the Employee Retirement Income Security Act (ERISA), courts focus heavily on the administrative record developed during the appeal process, which is why we prioritize building a complete and organized record from the start.

Step 6: Resolution and ongoing support

If the appeal is granted, the plan may approve coverage consistent with its terms. If the denial is upheld, we explain remaining options in plain language and help you decide what comes next.

Why Choose Appeal Healthcare?

• Strategic focus on healthcare denial appeals: This is the core of our practice.
• Kentucky and Ohio representation: Licensed support familiar with the rules that often govern these plans.
• Fluent in medical and plan reasoning: We translate records and plan language into a coherent, evidence-backed appeal.
• You focus on health, we handle the process: We manage documents, deadlines, and insurer communications so you are not doing this alone.

Call (859) 372-6670 or contact us to discuss next steps and submit your denial letter for review.