UnitedHealthcare Claim Denied: Your Rights and How to Appeal

UnitedHealthcare Claim Denied: A Complete Appeal Guide

UnitedHealthcare (UHC) is the largest single health insurer in the United States, covering over 50 million Americans. With that scale comes a high volume of claim denials — and in recent years, UHC has faced significant regulatory scrutiny and litigation over its claims practices, particularly its use of AI-driven claims denial systems.

The important message: UHC denials are not final. You have federally mandated rights to internal appeal and free external review, and UHC decisions are overturned at meaningful rates when properly challenged.

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UHC's Denial Problem: Context That Helps You Appeal

In 2023 and 2024, UHC faced multiple lawsuits and congressional investigations over its use of an AI algorithm (nH Predict) to deny post-acute care claims. A Reuters investigation found the algorithm had a 90% override rate when doctors appealed — meaning the denials were overwhelmingly wrong. A federal class action lawsuit alleged UHC used the algorithm to systematically deny coverage that patients were legally entitled to.

This context matters for your appeal because:

• Courts and regulators are increasingly skeptical of automated UHC denials
• UHC has faced pressure to improve its appeals handling
• The paper trail from your appeal is essential if the case escalates to litigation

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Why UHC Claims Are Denied

Common UHC denial reasons:

• Medical necessity: UHC's internal clinical guidelines don't support the treatment
• Prior authorization not obtained or denied: Required pre-approval was missing or refused
• Out-of-network: Provider was not in UHC's network
• Experimental or investigational: UHC classifies the treatment as not yet standard of care
• Coding or administrative errors: Claim submitted with incorrect codes by the provider
• Benefit limit exceeded: You've hit a coverage cap for specific services
• Coordination of benefits: UHC disputes which insurer is primary

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Understanding UHC's Appeal Levels

UHC's internal appeal process has up to two levels:

Level 1: First-Level Appeal

• Deadline to file: Within 180 days of the denial notice (check your denial letter — some plan types have shorter deadlines)
• UHC decision timeline: 30 days for pre-service (non-urgent) / 60 days for post-service / 72 hours for urgent/expedited
• Submit to: The address listed on your denial letter, or through myuhc.com member portal

What to include:

• Your UHC member ID and claim/reference numbers
• A written appeal letter explaining why the denial should be reversed
• Letter from your treating physician stating medical necessity
• Relevant medical records
• Clinical guidelines supporting the treatment

Level 2: Second-Level Internal Appeal

If Level 1 is denied, UHC may offer a second-level review. This is optional but can be worthwhile if you have additional evidence to present. However, you are not required to complete a second-level appeal before requesting external review.

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Prior Authorization Disputes: The Peer-to-Peer Call

If UHC denied a prior authorization request, your physician's most powerful tool is requesting a peer-to-peer review — a direct phone call between your physician and UHC's medical director.

How to request:

• Your provider calls UHC's Provider Services line (the number is on UHC's provider portal)
• The call must typically be requested within a few days of the denial
• Your physician presents the clinical case directly, explaining why the treatment is medically necessary for you specifically
• The UHC medical director can reverse the prior auth denial on the call

Multiple studies show peer-to-peer reviews result in prior auth reversals in approximately 50–60% of cases. This is often faster than a written appeal.

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Urgent/Expedited Appeals: When 72 Hours Matters

If your health situation is time-sensitive — meaning waiting 30+ days for a standard appeal decision could seriously harm your health — request an expedited appeal.

Criteria for expedited appeal:

• The denial involves ongoing care that will be interrupted
• Waiting for the standard review timeline could seriously jeopardize your health, life, or ability to regain function
• Your physician certifies the urgent nature of the situation

UHC must decide an expedited appeal within 72 hours. You can also request expedited external review simultaneously with your internal expedited appeal if the situation is truly urgent.

Important: Request expedited status explicitly in writing and have your physician document the urgency in their supporting letter.

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Free External Review

After exhausting internal appeals (or for urgent cases, simultaneously), you have the right to free, independent external review under the ACA.

How to Request UHC External Review

1. Your final UHC denial letter must include external review instructions and the name of the approved IRO
2. File your external review request within 4 months of the final internal denial
3. Submit all medical documentation to the IRO

The IRO reviews the clinical evidence independently of UHC. If the IRO overturns the denial, UHC must cover the treatment or service — this is legally binding.

State-Specific External Review Options

• California: Submit an Independent Medical Review request to the Department of Managed Health Care (DMHC) at 1-888-466-2219. California's process is often faster than federal external review.
• New York: New York State Department of Financial Services oversees external appeals
• Other states: Contact your State Department of Insurance

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Challenging UHC's Medical Necessity Determinations

UHC uses proprietary clinical guidelines called InterQual and MCG (Milliman Care Guidelines) to make medical necessity determinations. These guidelines are more restrictive than what most physicians consider medically appropriate.

To challenge a medical necessity denial effectively:

1. Request the specific guideline applied. Ask UHC in writing to provide the exact InterQual or MCG criteria used to deny your claim. You are entitled to this information.

2. Compare against recognized national guidelines. Show that your treatment follows guidelines from recognized specialty societies:

• American Cancer Society / NCCN (cancer treatments)
• American College of Cardiology (cardiac procedures)
• American Psychiatric Association (mental health)
• Relevant specialty society for your condition

3. Have your specialist write a point-by-point rebuttal. Your physician should address each specific criterion UHC applied and explain why your clinical situation meets or exceeds the threshold.

4. Cite mental health parity if applicable. If your denial involves mental health or substance use disorder treatment, UHC must apply the same level of scrutiny they apply to comparable medical/surgical benefits under the Mental Health Parity and Addiction Equity Act (MHPAEA).

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Reporting UHC to Regulators

If UHC violates your procedural rights — missing decision deadlines, failing to provide required notices, or acting in bad faith — report them:

• State Department of Insurance: For fully insured plans governed by state law
• Employee Benefits Security Administration (EBSA): For ERISA employer plans — 1-866-444-EBSA
• Centers for Medicare & Medicaid Services (CMS): For marketplace plans
• State Attorney General: For systemic bad-faith practices

Filing regulatory complaints creates a record and often prompts internal review. Insurers take regulatory attention seriously.

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UHC-Specific Tips From Successful Appeals

Get everything in writing. UHC has a documented pattern of verbal communications that don't match subsequent written decisions. Every phone call should be confirmed with a written follow-up email.

Document every contact. Record the name of every representative you speak with, the date and time, and what was said.

Request your complete claims file. Before filing your appeal, request all documents UHC used in the review — including the specific criteria applied and the reviewer's qualifications.

Know that AI-driven denials are vulnerable. If your denial came quickly (within days of submission) without apparent individualized clinical review, it may have been AI-generated. Human clinical review on appeal often produces different results.

Appeal the appeal if denied. Many people give up after a single denial. The external review overturn rate demonstrates that persistence pays.

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Common Mistakes When Appealing UHC Denials

1. Not meeting the filing deadline. 180 days is the federal minimum, but some UHC plans have shorter windows. Check your denial letter immediately.

2. Submitting the appeal without physician support. UHC rarely reverses medical necessity denials without a supporting physician letter. This is non-negotiable.

3. Not requesting the specific guidelines used. Without knowing the exact criteria, you can't rebut them effectively.

4. Forgetting about peer-to-peer for prior auths. This is faster and more effective than written appeals for prior auth disputes.

5. Not pursuing mental health parity violations. MHPAEA violations are common with UHC and regulators take them seriously. If the denial involves mental health or substance use treatment, always check for parity issues.

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Getting Help With Your Appeal

Navigating UHC's multi-level appeal process while managing a health condition is genuinely challenging. ClaimBack can help you generate a structured, evidence-based appeal letter tailored to UHC's specific denial reasons and the regulatory framework that applies to your plan type. Visit claimback.app to get your appeal letter started.

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Summary: UHC Appeal The Full Fight

1. Read your denial letter carefully — identify the denial reason, appeal deadline, and external review information
2. Have your physician request a peer-to-peer call for prior authorization denials
3. File Level 1 internal appeal within 180 days (or sooner — check your plan) with physician letter and medical evidence
4. Request expedited review if your situation is medically urgent
5. Request free external review after exhausting internal appeals — within 4 months of final denial
6. File a regulatory complaint if UHC misses deadlines or violates procedural requirements
7. Consult an attorney for ERISA plans with high-value denials or bad-faith conduct