Insurance Appeals

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Last updated: June 5, 2020

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This section tells you how to appeal decisions that the Marketplace or your health insurance company makes that you don't agree with.

What is an appeal? 

You can appeal any decision, action, or inaction that you do not agree with that has been made by the Marketplace or your insurance company (for example, if your health insurance company doesn’t pay for a specific health care provider or service prescribed by your doctor). Depending on the situation, you can appeal directly to the Marketplace, to the insurance company and/or to the Illinois Department of Insurance (DOI).

Marketplace Appeals

An appeal is a legal action you can take when you receive a final eligibility decision from the Marketplace and you do not agree with it. You generally have 90 days from when the decision is made to appeal it. You can mail or fax appeals to the Marketplace. Appeal forms are available here but you can also submit a description of your appeal issues in a letter.

What types of decisions can be appealed to the Marketplace?

• Denial of premium tax credits or CSRs (cost sharing reductions)
• Amount of premium tax credits or CSRs (cost sharing reductions)
• Denial of eligibility to enroll in marketplace coverage
• Denial of a special enrollment period (SEP)
• Termination of marketplace coverage

Health Insurance Appeals

An insurer appeal is the process you can use to have your plan’s benefits or insurer’s decisions reviewed. Examples of issues you can appeal include:

  • a doctor was listed as in-network, but when you try to see them, the provider doesn’t accept your insurance
  • you went to the emergency room and the your bill says the provider was out-of-network and you owe money
  • the insurer denied a claim for a covered service or procedure

In these situations, the first step is to contact your insurance company to find out how to file an appeal. You can look at your insurance card for the customer service phone number. Most appeals need to be filed within 180 days of receiving a claim denial or decision you don’t agree with.

Here is specific information if your health plan has denied a mental health or substance disorder service.

For more information on how to file an insurance company appeal, go here.

If you don’t agree with the insurer’s decision, you can also ask for an external review to have an independent 3rd party review your case.

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Need More Help?

If you need help filing an appeal or have any other questions about your insurance and your appeal rights, you can contact the Illinois Department of Insurance, Office of Consumer Health Information (OCHI): (877) 527-9431 or DOI.complaints@illinois.gov