A denied claim: the appeal ladder, the deadline, and what to send

Two things put a denial letter in front of you. Either a claim you filed has come back refused, or a pre-authorization for something already scheduled has been turned down. Both feel like the end of a process. Neither is.

The letter is a decision document and it is also a set of instructions, and the instructions are the part that decides the outcome. It names what kind of coverage you have, the reason for the refusal and often a code for it, the deadline for challenging it, and where the challenge goes. Read those four things before you decide anything, because the mistake that costs the most here is not losing an appeal — it is running the wrong one, on the wrong clock, or waiting for a “final answer” the plan has already given you.

The rules below are two different systems. Federal regulation governs employee benefit plans and health insurance issuers: the internal-appeal and independent-external-review rules in 29 CFR 2560.503-1 and 29 CFR 2590.715-2719. Everything else in insurance — auto, home, renters, life, and disability income policies bought on your own — is a contract regulated by your state, so the process and the deadlines vary by state and the place to look is your policy and your state insurance department. Medicare runs a third, separate ladder. Which one you are on is a fact about your coverage, not a choice.

What the letter has to tell you

Federal rules make the denial notice carry its own instructions. For a non-grandfathered group health plan, the notice must state the reason for the denial including the denial code and its meaning, describe the plan’s standard that was used, and describe the available internal appeal and external review processes along with how to start an appeal. Employee benefit plans generally must describe the review procedures and their time limits, including your right to bring a civil action under ERISA section 502(a). You can also ask for more than the letter volunteers: the plan must give you the diagnosis and treatment codes and their meanings on request, and it must give you, free of charge, access to and copies of all documents, records and other information relevant to your claim.

Find this	It looks like	Why it decides things
The type of coverage	“Group Health Plan” and a plan administrator, or an insurer name and policy number, or a Medicare plan card	It selects the ladder, and the ladder sets every deadline
The reason, and its code	“Not medically necessary,” “experimental or investigational,” “out of network,” “not eligible under the plan,” plus a code	Medical-judgment denials can reach an independent reviewer; eligibility denials under the plan’s own terms cannot reach the federal external review process
The deadline and the address	A date, a fax number, a portal, a mailing address, sometimes a named appeal unit	Missing it ends the process; a longer period than the federal minimum binds the plan
The name of anyone consulted	A physician reviewer or a medical director, sometimes with a specialty	A group health plan must identify the medical or vocational experts whose advice it obtained, whether or not that advice was relied on, and you can answer what they concluded

Two traps live in this list. The first is the denial that is really an eligibility decision wearing medical language: under the federal external review process an adverse determination based on a failure to meet the plan’s eligibility requirements is not eligible for external review, so if your letter’s real reason is coverage eligibility rather than medical judgment, the argument to make is a different one, and it starts with the plan document rather than with your doctor. The second is the deadline you were told informally on the phone. What governs is what the notice says and what the plan’s own procedures say, which is why every call in this process deserves a written follow-up.

Three ladders, and which one you are on

What your coverage is	Who writes the rules	The route
A health plan from an employer or a union, including a self-funded plan	Federal: ERISA, plus the Affordable Care Act’s claims rules for plans that are not grandfathered	Internal appeal to the plan, then independent external review
A Marketplace plan, or an individual or family health policy	A federal floor, then your state’s external review process where it meets federal standards	Internal appeal, then external review
An employer long-term disability plan	Federal: ERISA	Internal appeal to the plan under the same regulation, on its own clocks — 45 days for the plan’s decision, extendable by 30 and then 30 more, and 45 days for the decision on appeal — then a court action under ERISA section 502(a). The independent external review described below belongs to the health coverage rules
Auto, home, renters, life, or disability income insurance you bought yourself	Your state	Whatever your policy provides, then a complaint to your state insurance department
Medicare — Original, Advantage, or a drug plan	Federal: the Centers for Medicare & Medicaid Services	Medicare’s own appeal levels

Two scope notes worth carrying into the rest of this page. Grandfathered health plans — plans in existence on March 23, 2010 that have not made certain significant changes — are generally outside the Affordable Care Act’s appeal provisions, though the ERISA timing rules still apply to them, and the external review provisions reach grandfathered coverage for a defined set of emergency, non-participating provider and air ambulance claims. And the external review right discussed below belongs to the health coverage rules; a homeowners, auto, life or individually bought disability policy is governed instead by your state’s law and by whatever dispute process the policy itself provides.

Ladder one: the plan’s clock, then yours

The federal rules fix two clocks for a group health plan: how long the plan may take to decide, and how long you have to object.

The claim	The plan must tell you
Urgent care	As soon as the medical situation requires, and no later than 72 hours after the plan receives the claim. If information is missing, the plan must say so within 24 hours, you get at least 48 hours to supply it, and the plan decides within 48 hours of the earlier of receiving it or your deadline passing
Before the service — prior authorization, for example	15 days, extendable once by up to 15 days, with at least 45 days for you to supply missing information
After the service	30 days, extendable once by up to 15 days, on the same terms

What makes a claim “urgent” is not a judgment call by the plan alone. The test is whether applying the ordinary timeframes could seriously jeopardize your life or health or your ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the care at issue — and a claim that a physician with knowledge of your condition determines is urgent must be treated as urgent.

Once you have the denial, the clock that matters most is yours:

Step	Your window	The plan’s window
File the internal appeal	At least 180 days from the notice (the general minimum for employee benefit claims that are not group health claims is 60 days)	—
Urgent care appeal	—	72 hours
Pre-service appeal	—	30 days with one appeal level, or 15 days for each of two
Post-service appeal	—	60 days with one appeal level, or 30 days for each of two
Request independent external review	4 months from the notice	—
External review decision	—	45 days standard, 72 hours expedited

The 180 days is a floor, not a target, and it is the window in which the appeal is assembled: the operative report, the letter of medical necessity, the specialist’s note, and the plan’s own criteria quoted back from the denial. The Department of Labor’s guidance to participants adds two practical details. Where a plan requires two levels of appeal, each review generally gets half the time allowed for one — and after a first denial the plan must give you a reasonable period to file the second, though not a full 180 days. And a plan may extend its own review timeline only with your consent.

What “full and fair review” actually means

Three guarantees turn the internal appeal from a formality into something worth doing.

A different decision-maker who owes the first decision no deference. For a group health plan — and, through the same regulation, a plan providing disability benefits — the review must not afford deference to the initial adverse determination, and it must be conducted by someone who is neither the person who made that determination nor that person’s subordinate. Where the denial rested in whole or in part on a medical judgment — including a determination that a treatment is experimental, investigational, or not medically necessary — the plan must consult a health care professional with appropriate training and experience in the field involved, and that professional must not be anyone consulted on the original decision.

The evidence, in advance. A non-grandfathered plan must give you, free of charge, any new or additional evidence or rationale it relies on far enough ahead of its final decision that you have a real chance to respond to it. If that evidence arrives so late that a response is impossible, the plan’s deadline for issuing the final decision is paused until you have had that chance.

Your file. On request and free of charge, you are entitled to access to and copies of all documents, records and other information relevant to your claim — including, where the plan relied on an internal rule, guideline or protocol, the specific document or a statement that one was used and a copy on request.

And a consequence that changes the arithmetic of a plan that mishandles the process: a plan or issuer that fails to strictly adhere to the internal claims and appeals requirements leaves the internal process deemed exhausted. You may go straight to external review, and you may also pursue remedies under ERISA section 502(a) on the basis that the plan failed to provide a reasonable process. One narrow exception exists for violations the plan can show were minimal, for good cause, and that did not and were unlikely to cause you prejudice or harm. Which is the practical reason to keep every envelope, every portal confirmation and every fax receipt: a proven procedural failure can move you up the ladder faster than a good argument.

Ladder two: the independent reviewer

This is the rung that goes outside the company, and it is the one designed to be decisive. After a final internal denial, a non-grandfathered plan must offer external review by an independent review organization that has no financial or professional tie to your insurer, and whose decision your insurer is required by law to accept.

Question	The rule
How long do I have?	4 months after you receive the denial notice. Where there is no corresponding date four months out, the first day of the fifth month is substituted, and a last day falling on a weekend or federal holiday moves to the next business day
Who decides, and how?	An independent reviewer, deciding de novo and not bound by the conclusions reached inside the plan
How long does it take?	45 days for standard review, 72 hours for expedited review, with written confirmation within 48 hours if the decision was given orally
Can I add evidence?	Yes. A state process must allow at least five business days to submit additional information in writing, and in the HHS-administered process the notice that your request is eligible tells you that you have ten business days. Either way the reviewer must consider what you submit
What does it cost?	The plan or issuer pays for the independent reviewer. Where a state process authorizes a filing fee, it is capped at $25, refundable if the denial is reversed and waivable for hardship, with a $75 annual cap per person
Which denials qualify?	Those involving medical judgment, including medical necessity, appropriateness, health care setting, level of care and effectiveness of a covered benefit, and determinations that a treatment is experimental or investigational — plus a cancellation of coverage based on a claim that you gave false or incomplete information when you applied. A denial resting solely on whether you meet the plan’s eligibility requirements is not eligible for the federal process
Is there a minimum claim size?	No. A process may not impose a minimum dollar amount for eligibility

In the ordinary case you finish the internal appeal first: external review is available once you have a final internal adverse benefit determination. Two shortcuts exist. In an urgent situation you may file the internal appeal and the external review at the same time. And if the plan failed to strictly adhere to the internal appeal rules, the internal process is deemed exhausted and you can go straight to the external reviewer.

Which reviewer handles your case depends on your state and your plan. State external review processes that meet the federal consumer protection standards in the NAIC Uniform Model Act take the place of the federal one, and the Department of Health and Human Services decides whether a state process qualifies. Where a state does not qualify, or the plan is a self-funded plan not subject to the state process, the HHS-administered federal process applies, and it is free. Your denial notice or your plan’s materials are supposed to tell you which organization handles your review, and the contact information for that organization is the thing to look for.

If your plan uses the second federal route, watch for dated notices. HealthCare.gov carries a notice that a request deadline falling between July 1 and August 3, 2026 was extended to October 2, 2026 for plans using the HHS-administered process — which may have affected residents of Alabama, Florida, Georgia, Texas, Wisconsin and U.S. territories other than Puerto Rico, as well as state and local government plans anywhere. That window has closed. The reason to know it existed is the general lesson: these deadlines can be moved by a notice published on HealthCare.gov rather than mailed to you, so the four months in the table above is the period to plan around — not the outer edge of what is possible, and not something to discover late.

One more protection runs underneath the whole appeal. A plan subject to these rules must provide continued coverage pending the outcome of an appeal, and benefits for an ongoing course of treatment cannot be reduced or terminated without advance notice and an opportunity for advance review.

Ladder three: a policy your state regulates

For auto, home, renters, life, and disability income policies bought on your own, the rules are a different set: insurance sold to people and businesses is regulated state by state, and what you have is a contract plus a regulator. That makes the procedure less standardized than the health process above — and it makes “varies by state” the operative phrase. The behavior a regulator can act on is the behavior the National Association of Insurance Commissioners lists: unfair claim delays or denials, a failure to honor your policy, a lack of timely communication. What counts as unreasonable, and any deadline attached to it, is set by your state, and the authority to check is your state’s department of insurance.

What is consistent is the route. The National Association of Insurance Commissioners describes it plainly: if you have a problem with your insurer, try to resolve it with them first, and if you are still not satisfied you can file a complaint with your state department of insurance, which protects policyholders and makes sure insurers follow the rules and treat consumers fairly. Complaints can be made in writing or verbally depending on your state’s process — the process varies by state, though most departments accept complaints online, by mail or by phone — and the department can investigate for free complaints involving unfair claim delays or denials, failure to honor your policy, violations of state insurance laws, lack of timely communication, and cancellations or nonrenewals you believe are unjustified. Once a complaint is within its authority, the department forwards it to the insurer, which must respond with its explanation. If the department finds the insurer acted improperly, it can require the company to correct the problem and comply with state law. And an insurer cannot discriminate against you in the future for having filed.

Two things to understand about what that process is and is not. It is a regulatory process aimed at the insurer’s conduct, not a substitute for the decision on your claim: the department reviews whether the company behaved fairly under your policy and can order corrective action, while the decision about what your policy owes you is made by the insurer or, if the policy provides for it, by whatever dispute mechanism the policy itself names. And it is a documented process, so it rewards the same discipline the health appeal does. Gather your policy number, documentation, bills and records; build a record of all communication including dates and times; use language from your policy where you can; and state the outcome you want. Filing a good complaint is largely a matter of being the person in the file who wrote things down.

If the dispute is over a bill that a provider or a collection agency is still pursuing, this network covers the adjoining question separately in medical debt and credit reports.

Medicare runs its own ladder

Medicare is neither of the above. You can appeal a coverage or payment decision by Original Medicare, by a Medicare Advantage or other Medicare health plan, or by a Medicare drug plan, and a plan must tell you in writing how to appeal. There are generally five levels of appeal, and the decision letter at each level explains how to reach the next. Two practical markers: for 2026, the minimum amount in controversy for judicial review in federal district court is $1,960, and claims can be combined to reach it; and if covered services are ending sooner than you believe they should, you have a right to a fast appeal, for which your provider must give you a written notice explaining how to ask. Free, personalized counseling is available through the State Health Insurance Assistance Program. The network’s own guides to Medicare enrollment and what one bill actually costs cover the coverage side.

When appealing is the wrong move

Appealing is not automatically the right answer, and the criteria are findable in the letter itself.

• Is the reason medical judgment or coverage eligibility? If the plan says the treatment is not medically necessary, or is experimental, you are arguing about clinical facts, and the appeal is the whole game — an independent reviewer who must disregard the insurer’s conclusion is a favorable forum. If the plan says the service is excluded from your plan, or that you were not eligible on the date of service, you are arguing about the plan document, and the useful work is finding the section the letter cites and reading what it actually says.
• Does the arithmetic work? An appeal costs you hours, records requests, and follow-up. A disputed amount in the low hundreds is still worth a written appeal when the treatment is likely to recur or when the point is the record — so decide which of those you are doing, rather than filing because filing feels right.
• Is the deadline already gone? Then the question changes from appeal to complaint, and the route is your state insurance department for a regulated policy, or the plan’s own voluntary process where one exists. A missed deadline is a reason to change tactics, not to stop.
• Is something time-critical still pending? If care is scheduled or ongoing, the urgent and expedited tracks exist for exactly this, including asking for the internal appeal and the external review at the same time.

What to send, and what to keep

The appeal itself is unglamorous and mostly mechanical. What goes in it:

1. A written request naming you, the claim number and your identification number, and the decision you are appealing. Where the plan supplies a form, complete it and attach the rest.
2. The clinical case, addressed to the reason the letter gave — a letter of medical necessity from the treating physician, the relevant records, and the guideline or criterion you believe the plan misapplied.
3. The plan provision you are relying on, quoted. Where the denial cited an internal guideline, ask for the document itself and answer it by name.
4. A request for your file — the documents, records and other information relevant to the claim, free of charge, and the identification of any medical or vocational expert whose advice was obtained.
5. Your authorizations, if a doctor, an advocate, or your state’s Consumer Assistance Program will act for you.

What to keep: the Explanation of Benefits and denial letters, copies of everything you send, the confirmation of every submission, and dated notes of every phone call including the day, the time, the name and the title of the person you spoke with. Every deadline in this article is proved or disproved by a document, and the plan holds the file. Your own log is the only part of the record you control.

The bottom line

A denial is a rung, not a wall, and reading the letter is what tells you which ladder you are climbing. Find four things — the type of coverage, the reason and its code, the deadline, and the address — and you already know whether an independent reviewer exists outside the company, whether the fight is about medicine or about a plan exclusion, and how long you have. The deadlines are generous where they matter most: 180 days to appeal a group health plan denial, four months to demand external review, and a reviewer whose decision the insurer is required to accept. The way people lose these cases is not by being wrong about the medicine. It is by being late, by arguing the wrong question, or by never filing at all.

This article is general information about insurance claims and appeals, not insurance or legal advice, and it is not a substitute for advice about your own coverage. Employer plans and health insurance are governed by federal rules; auto, home, life and individually bought disability policies are regulated by the states, so procedures, deadlines and complaint processes vary by state, and your policy and your state’s insurance department control. It is AI-written and independently AI-reviewed before publication; the review standard and this article’s findings are recorded in the network’s editorial review log.