--- title: Denied Claims: How to Appeal in Tennessee url: https://www.tnhealthcoverageexplained.org/using-your-plan/appeals description: Denied claim in Tennessee? The ladder that works: read the denial letter, file an internal appeal, then request independent external review through TDCI. last_verified: 2026-10-17 publisher: TN Health Coverage Explained (independent; does not sell insurance) --- # Denied Claims: How to Appeal in Tennessee A denied claim isn't the final word. There's a ladder, and it works: **read the denial letter, appeal inside your plan, and if that fails, ask the state for an independent external review.** Here's each rung, in order. ## Rung 1: Read the denial letter Your denial letter (sometimes called an Explanation of Benefits or adverse benefit determination) tells you two critical things: **why** the claim was denied, and **your deadline** to appeal. Treat that deadline as the authority — miss it and you can lose the right to appeal entirely. Keep the letter; you'll reference it at every step. ## Rung 2: The internal appeal File an appeal with your plan — the denial letter and your plan documents explain exactly how. Practical tips that actually matter: - **Get your doctor involved early.** A letter from your clinician explaining why the care was medically necessary carries real weight. - **Reference the plan language.** Point to the specific benefit or provision you believe covers the care. - **Keep copies of everything** you send and receive. - **Write down names, dates, and reference numbers** for every phone call. You must **exhaust this step first** — external review isn't available until your plan's internal appeal process is finished. ## Rung 3: Independent external review through TDCI After your plan's internal appeal is complete, you can request **external review** through the Tennessee Department of Commerce & Insurance (TDCI). Here's what that means: - **Independent clinicians** with no stake in the outcome re-examine your case — not your insurer, not anyone paid by your insurer. - It's typically used for denials based on **medical necessity** or because the care was deemed **experimental or investigational**. - The decision is **generally binding on the plan**. If the reviewers overturn the denial, the plan has to cover the care. **How to reach TDCI's Consumer Insurance Services:** call (615) 741-2218 or 1-800-342-4029; file online at tn.gov/commerce/insurance/consumer-resources/file-a-complaint.html; or write to 500 James Robertson Parkway, 10th Floor, Nashville, TN 37243-0574. ## If the process itself breaks down If your plan won't follow the appeal rules — ignoring deadlines, refusing to provide required notices, stonewalling — file a **complaint with TDCI** using the same contacts above. The complaint process and the appeal process are different tools; use the complaint when the *process* is the problem. ## Know which door is yours Not every plan answers to TDCI. Using the wrong door wastes weeks: - **Marketplace and most individual plans, plus many small-employer plans:** these are fully insured and regulated by the state — **TDCI** is your agency. - **Self-funded employer plans** (large or multi-state employers that pay claims themselves rather than buying insurance): regulated by the **U.S. Department of Labor's Employee Benefits Security Administration** — (866) 444-3272. TDCI can't take these cases. - **TennCare managed-care disputes** (BlueCare, Wellpoint, UHC Community Plan): go through **TennCare**, not TDCI. - **Medicare questions:** the Tennessee SHIP program offers free, unbiased counseling — 1-877-801-0044. Not sure which type your plan is? Ask your HR department or benefits administrator whether the plan is self-funded — they're required to tell you. ## Practical tips for the whole process - **Keep copies of everything.** Every letter, every form, every email — both directions. - **Log every call:** name, date, time, reference number, and what was said. - **Don't miss the deadline** in your denial letter. Calendar it the day the letter arrives. - **Get your doctor involved early**, not after the second denial. - **Keep paying your premiums** so your coverage stays active while you appeal. - **Don't ignore the underlying bill.** Ask the provider — in writing if you can — to hold the account while the appeal is pending. ## Frequently asked questions **My claim was denied. What's the very first thing I should do?** Read the denial letter carefully: note the reason for the denial and your appeal deadline. Calendar the deadline immediately, then start the plan's internal appeal. **What's the difference between an internal appeal and external review?** An internal appeal asks your plan to reconsider its own decision. External review — available only after the internal appeal is exhausted — puts your case before independent clinicians through TDCI, and the decision is generally binding on the plan. **Who handles external review in Tennessee?** The Tennessee Department of Commerce & Insurance (TDCI), Consumer Insurance Services: (615) 741-2218 or 1-800-342-4029. **Is the external review decision binding on my plan?** Generally, yes. If the independent reviewers overturn the denial, the plan must cover the care. **How long do I have to file an appeal?** Your denial letter states your filing deadline — treat it as the authority. For ACA plans, federal rules require at least 180 days from the denial to file an internal appeal, but file as early as you can. **My plan is through my employer's self-funded plan. Where do I appeal?** Start with the plan's own internal appeal process, then — for external help — contact the U.S. Department of Labor's Employee Benefits Security Administration at (866) 444-3272. TDCI doesn't regulate self-funded plans. **I'm on TennCare and my health plan denied something. What do I do?** TennCare managed-care disputes go through TennCare, not TDCI. Follow the appeal instructions in your TennCare notices. **What if the appeal process itself isn't working?** File a complaint with TDCI's Consumer Insurance Services — (615) 741-2218 or 1-800-342-4029, or the online complaint form at tn.gov/commerce/insurance/consumer-resources/file-a-complaint.html. **Should I keep paying the bill while I appeal?** Don't ignore it. Ask the provider to hold the account while the appeal is pending — in writing if you can — and keep paying your premiums so your coverage stays active. ## Keep reading - [Prior authorization and referrals](https://www.tnhealthcoverageexplained.org/using-your-plan/prior-authorization) - [What you'll pay: costs explained](https://www.tnhealthcoverageexplained.org/using-your-plan/costs-explained) - [Provider networks: HMO, PPO, EPO](https://www.tnhealthcoverageexplained.org/using-your-plan/networks) - [How we verify our information](https://www.tnhealthcoverageexplained.org/how-we-verify) - [Glossary](https://www.tnhealthcoverageexplained.org/glossary) ## Sources - Tennessee Department of Commerce & Insurance (TDCI) — Consumer Insurance Services, external review, complaint filing - U.S. Department of Labor, Employee Benefits Security Administration (EBSA) — self-funded plan oversight - HealthCare.gov — appeals and external review explanations - Centers for Medicare & Medicaid Services (CMS) Every figure and claim on this site is checked against primary sources. See [how we verify](https://www.tnhealthcoverageexplained.org/how-we-verify).