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Yes, health insurers may use AI in processes that affect claims or coverage—but that does not establish that every insurer uses it, or that an algorithm made a particular denial without human judgment. If your plan denies a claim, the denial notice should explain why and how to dispute it. Depending on your coverage and the decision, you may be able to appeal internally and then seek independent external review. The official guidance cited here does not establish a universal nationwide right to be told whether AI played a role in a specific decision.
Can my health insurer use AI to deny my claim?
AI may be used somewhere in claims handling, prior authorization, or utilization management. That is different from proving that an AI system independently made your denial. The Centers for Medicare & Medicaid Services (CMS) identifies oversight of AI use by Medicare Part C and Part D plans in prior authorization and utilization management as an agency use case, including attention to potential compliance, bias, and beneficiary-outcome problems. This shows regulatory attention to the issue; it does not establish what a particular insurer used in your case.
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The National Association of Insurance Commissioners (NAIC) Consumer Liaison Committee’s November 2024 report recommends giving patients and providers a reason for every denial, disclosing AI’s role up front, and providing meaningful human clinical oversight when AI recommends a denial. These are the committee’s policy recommendations, not by themselves binding nationwide requirements. The report is not a study of how often insurers use AI or how often AI-related appeals succeed.
Can I ask whether AI made the decision?
Yes. You can ask your insurer, in writing, whether an automated or AI-based tool was involved, what part it played, whether a person reviewed the decision, and what records or criteria support the denial. Keep the response with your appeal documents. Asking may help clarify what happened, but the official materials cited here do not establish a universal right to disclosure of every tool’s role, model logic, source code, or all data it processed.
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CMS consumer guidance describes rights to information about a denial and to see and respond to information used in an internal appeal decision. If relevant, request the records and criteria applicable to your denial through the plan’s stated process. Do not assume that an ordinary appeal entitles you to an algorithm audit or the insurer’s model code.
What happens to my health information?
The sources cited here do not establish a comprehensive, insurer-specific rule requiring disclosure of every data point an AI model used or every third party that may have accessed claim information. Privacy rights depend on the organization, the information, and the laws that apply to the situation. CMS guidance last reviewed August 26, 2025, advises CMS staff not to put sensitive personal or health information into publicly accessible AI tools. That is agency guidance for CMS staff—not a complete statement of private insurers’ obligations or a consumer privacy rule.
- Use the insurer’s official appeal channel and send only information relevant to the claim.
- Keep a copy of everything you submit and ask the plan what information and criteria support its decision.
- Do not assume an ordinary appeal will provide access to source code, all model inputs, or a full AI audit.
How do I appeal a health insurance denial?
- Read the denial notice and Explanation of Benefits (EOB). Note the service denied, the stated reason, the notice date, the appeal route, and the deadline. Determine whether the stated issue is, for example, medical necessity, a benefit exclusion, an out-of-network service, or an experimental-treatment determination.
- Check your plan documents and coverage type. If you have employer coverage, ask HR whether the plan is self-funded or fully insured; the procedures and oversight can differ. The plan documents and notice help identify the process that applies.
- File the internal appeal by the deadline in your notice. Use the insurer’s form or follow its instructions for submitting a written appeal. Identify yourself and the claim, explain why you dispute the reason given, and attach relevant support such as a clinician’s letter. Keep proof of submission.
- Request relevant decision records if needed. Ask for information about the denial and the material used in the internal appeal decision so you can respond to it. Use the plan’s process and keep copies of your request and any response.
- Consider external review if the denial remains and your case is eligible. An independent reviewer—not the insurer—reviews eligible disputes. Urgent-care cases may have expedited or concurrent review options. Under the described process, the insurer must accept the external reviewer’s decision.
- Get help if the route is unclear. CMS and HealthCare.gov direct consumers to state Consumer Assistance Programs and state insurance regulators where available.
Keep a record of the appeal
- The denial letter, EOB, and applicable plan document or summary plan description.
- Appeal forms, letters, supporting medical information, and records the insurer provides.
- Proof of when and how you sent each submission.
- Notes of calls, including the date and time, the representative’s name and title, and what was discussed.
Keep originals where possible and send copies. HealthCare.gov’s appeal guidance recommends retaining the denial and EOB, appeal materials, supporting information, and dated call notes.
What deadlines apply?
HealthCare.gov describes the following general timelines. They are guidance, not a substitute for the deadline and process in your notice, plan documents, or applicable state procedure. Urgent cases may have faster timelines.
| Step | General timeline described by HealthCare.gov |
|---|---|
| Insurer sends a denial notice | Within 15 days for prior authorization; 30 days for services already received; or 72 hours for urgent-care cases. |
| Request an internal appeal | Generally within 180 days after the denial notice. |
| Insurer decides an internal appeal | Within 30 days for a pre-service appeal or 60 days for a post-service appeal; urgent cases may be faster. |
| Request external review | HealthCare.gov describes a general filing period of four months. Check the final denial and applicable process for the actual deadline. |
| External reviewer decides | Up to 45 days for standard review or 72 hours for expedited review, as described by HealthCare.gov. |
These timelines do not necessarily apply to every plan or claim. Coverage type—including individual, Marketplace, employer-sponsored, self-funded, fully insured, or Medicare-related coverage—and state law can affect the route. CMS explains that a state process meeting federal minimum standards may govern external review, with a federal process applying in certain circumstances. Follow the instructions for your own coverage rather than relying on a general figure.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.How to tell which appeal route fits
- Internal appeal: Ask the insurer to reconsider its decision using the process in your notice.
- External review: If the denial is eligible and remains after the applicable process, request review by an independent reviewer.
- Urgent versus standard: If waiting could seriously affect your health, ask the plan about expedited or concurrent review and follow the urgent instructions in your notice.
- Medical judgment versus administration: A dispute about medical necessity may need clinical support; a dispute about a benefit or network rule may call for the relevant plan provision or claim record.
- Employer plan type: Find out whether an employer plan is self-funded or fully insured, because procedures and oversight can differ.
For a live dispute, use the plan notice and current plan documents as your starting point. A state regulator, Consumer Assistance Program, or qualified benefits or legal adviser can help clarify the procedure for your coverage.
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