How to file a second-level appeal if the first is denied
A first-level denial is not the end. Depending on the plan, you have one or two more internal levels, then external review. Here is how to sequence them.
Does your plan have a second internal level
Under ACA section 2719 (45 CFR 147.136), a non-grandfathered plan is only required to provide one internal appeal level for individual plans, and up to two for group health plans (with an option to combine into one). Read your denial letter and your Summary Plan Description (SPD) or Certificate of Coverage.
- If the first-level denial letter mentions a "second-level appeal" or "reconsideration," you have another internal step
- If the letter says "this is our final decision," it may still not be truly final; ask specifically whether second-level exists
- If your plan is a self-funded ERISA plan, the SPD spells out the number of levels
If you have $99 or $199 tier
Your PDF includes a second-level template. Open it, fill in the date, and use it as the base for your second-level letter. Attach the first-level denial letter as the enclosure.
If you only have $49 tier
Email support with your appeal ID and we will supply the second-level template at cost. See How to request a refund for tier changes.
Timing
- The second-level appeal window is typically shorter than the first. Usually 60 days from the first-level denial date, not 180
- Read the first-level denial letter for the exact window
- For Medicare Advantage, there is no plan-level second appeal; missed deadlines auto-forward to the IRE
What to include in the second-level
- A new cover letter dated today
- The first-level denial letter
- Your original appeal letter
- Any new information the plan requested and you provided (if any)
- A new cited argument responsive to the plan's stated reason for denying at first-level
Do not rehash
The second-level reviewer usually has access to the first-level file. Do not simply resubmit the same letter. Respond to what the plan said in its denial. If the plan said "not medically necessary" and cited clinical criteria you did not address, address them now.
When to skip second-level and go straight to external
You can skip second-level and go straight to external review if:
- Your plan does not offer a second internal level
- The plan missed its regulatory deadline on the first-level (deemed exhaustion, see What if you don't hear back in 30 days)
- Your situation is urgent enough that you cannot wait another 60 days
- The plan waived second-level in a settlement or written agreement
When second-level is worth doing anyway
- The plan gave a specific reason at first-level and you have new information that responds directly to it
- The dollar amount is significant enough that you want another shot with a different reviewer
- External review will use the internal record; a strong second-level appeal strengthens what the external reviewer sees
After second-level
- If reversed, you are done
- If denied, you can request external review under ACA section 2719 for non-grandfathered plans. See How to request an external review
- If ERISA and both internal levels are done, you can also file suit under ERISA section 502(a)(1)(B). See When to hire an ERISA attorney