Claim appeal deadlines: which clock applies to your plan
The 180 days to file, the plan's 72-hour, 15-day and 30-day clocks, and the four months for independent review — by type of coverage.
Which process applies is a fact about your coverage, not a choice. Open the one you hold, then check the deadline printed on your own denial letter against it — where the letter gives you longer, that longer period is the one you have.
A health plan from an employer or a union, including a self-funded plan
Internal appeal to the plan, then independent external review
First clock: 180 days from the notice to file the internal appeal.
The review must give no deference to the original decision, and a denial that rested on a medical judgment must go to a professional in that field who was not consulted the first time.
A Marketplace plan, or an individual or family health policy
Internal appeal, then external review
First clock: 180 days from the notice to file the internal appeal.
In an urgent situation the internal appeal and the external review can be filed at the same time, and your state consumer assistance program can file the appeal for you.
An employer long-term disability plan
Internal appeal to the plan, then a court action under ERISA section 502(a)
First clock: 180 days from the notice to file the internal appeal.
The independent external review described on this page belongs to the health coverage rules. A disability plan is decided inside the plan and then in court.
Auto, home, renters, life, or disability income insurance you bought yourself
Whatever your policy provides, then a complaint to your state insurance department
First clock: Whatever the policy says — there is no federal 180-day minimum here.
The federal internal-appeal and external-review rules are part of the health coverage rules. They do not reach a policy you bought for your car or your house.
Medicare — Original, Advantage, or a drug plan
Medicare's own appeal levels
First clock: The decision letter at each level explains how to move to the next.
A Medicare Advantage or drug plan must tell you in writing how to appeal its decision. The health-plan ladder on this page is a different system.
These are the federal minimums for a group health plan. A plan may give you more time; it may not give you less. The plan's own clock starts when it receives the claim, not when you mailed it.
| Step | Your window | The plan's window |
|---|---|---|
| File the internal appeal | At least 180 days from the notice | — |
| Urgent care appeal | — | 72 hours |
| Pre-service appeal | — | 30 days with one appeal level, 15 days for each of two |
| Post-service appeal | — | 60 days with one appeal level, 30 days for each of two |
| Request independent external review | 4 months from the notice | — |
| External review decision | — | 45 days standard, 72 hours expedited |
One failure is worth knowing about in advance: if a plan does not strictly follow the internal claims and appeals rules, the internal process is treated as exhausted, and you may go straight to external review — and sue under ERISA section 502(a) for the process itself. Keep every envelope and every timestamp.
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 stands in, and a last day on a weekend or federal holiday moves to the next business day.
Who decides?
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 — at least five business days in a state process, ten business days in the HHS-administered process.
What does it cost?
The plan or issuer pays the reviewer. A state filing fee is capped at $25, refundable if the denial is reversed, waivable for hardship, with a $75 annual cap per person.
Which denials qualify?
Those involving medical judgment, and determinations that a treatment is experimental or investigational — plus a cancellation of coverage based on a claim that you gave false information when you applied. A denial resting solely on whether you meet the plan's eligibility rules is not eligible for the federal process.
The deadline that decides a denied claim is printed on the denial letter, and it is the first thing worth finding. Everything else — what to argue, what to attach, who to call — is downstream of it.
What the letter does not always make clear is which system you are in, and that is the fork this page is built around. Federal regulation governs employee benefit plans and health insurance issuers. Medicare runs a separate ladder. And a policy you bought for your car, your house or your life is a contract governed by your state, with whatever process the contract provides.
What the notice has to tell you
For a non-grandfathered group health plan, the denial notice must state the reason including the denial code and its meaning, describe the plan’s standard that was used, and describe the internal appeal and external review processes along with how to start one. You can also ask for more than the letter volunteers: the diagnosis and treatment codes and their meanings, copies of the documents relevant to your claim free of charge, and — where a medical or vocational expert was consulted — the identity of that expert, whether or not the advice was relied on.
Read those four things before deciding anything: what kind of coverage it is, the reason and its code, the deadline and the address, and who was consulted. The mistake that costs the most here is not losing an appeal. It is running the wrong one, on the wrong clock.
The clocks, in order
For a health plan, the sequence is fixed and the numbers are federal minimums:
- You have at least 180 days from the notice to file the internal appeal.
- The plan has 72 hours for an urgent claim, 15 days for a pre-service claim and 30 days for a post-service claim, each extendable once by up to 15 days.
- The plan has 72 hours for an urgent appeal, and 30 days or 60 days for a pre-service or post-service appeal where it offers one level — half that for each of two.
- You have 4 months from the notice to request independent external review.
- The reviewer has 45 days, or 72 hours if the review is expedited.
A plan may give you longer than the minimum. It may not give you less. Its own clock starts when it receives the claim, not when you mailed it.
Two things that change the shape of the fight
A missed deadline can end the internal process in your favor. If a plan does not strictly follow the internal claims and appeals requirements, the internal process is deemed exhausted, and you may go straight to external review — and sue under ERISA section 502(a) for the process itself. There is a narrow exception for violations the plan can show were minimal, for good cause, and did not prejudice you.
Not every denial can reach an independent reviewer. A denial resting solely on whether you meet the plan’s eligibility requirements is outside the federal external review process. A denial involving medical judgment — necessity, appropriateness, setting, level of care, effectiveness, or whether a treatment is experimental — is inside it.
The full account of what to put in the appeal, how the review must be conducted, and what to do when a plan treats its own deadline as optional is in A denied claim: the appeal ladder, the deadline, and what to send. The insurance-cost side of the same bill — deductible, coinsurance, out-of-pocket maximum — is in Deductible, coinsurance, out-of-pocket max.
Frequently asked questions
- How long do I have to appeal a denied health claim?
- For a group health plan — the kind you get through an employer or a union — the federal minimum is at least 180 days from the date you receive the notice of denial. For other employee benefit claims the general minimum is 60 days. The number that binds you is the one printed in your denial letter, and it is worth finding first: if the letter gives you more than the minimum, that longer period is the one you have.
- What counts as urgent?
- The regulation defines a claim involving urgent care, and it is not limited to emergencies: it includes a situation where applying the non-urgent timeframes could seriously jeopardize your life or health, or your ability to regain maximum function, and severe pain that cannot be adequately managed without the care or treatment at issue. Urgent claims get 72 hours at the plan, not 15 or 30 days.
- Which denials cannot go to independent external review?
- A denial that rests solely on whether you meet the plan's eligibility requirements under its own terms. Denials that involve medical judgment — medical necessity, appropriateness, the health care setting, the level of care, effectiveness, or whether a treatment is experimental or investigational — can reach an independent reviewer. So can a cancellation of coverage based on a claim that you gave false or incomplete information when you applied.
- What if the plan misses its own deadline?
- The rules turn a procedural failure into an advantage. If a plan does not strictly adhere to the internal claims and appeals requirements, the internal process is deemed exhausted: you may go straight to external review, and you may also sue under ERISA section 502(a) on the basis that the plan failed to provide a reasonable process. There is a narrow exception for violations the plan can show were minimal, for good cause, and did not prejudice you — which is why you keep every envelope and timestamp.
Sources
- Electronic Code of Federal Regulations — 29 CFR 2560.503-1, Claims procedure: (f)(2)(i) urgent care claims decided no later than 72 hours after receipt, with a 24-hour notice if information is missing and at least 48 hours to supply it; (f)(2)(iii) pre-service claims within 15 days and post-service claims within 30 days, each extendable once by up to 15; (h)(3)(i) at least 180 days for a group health plan to receive an appeal; (i)(2) appeal decision clocks of 72 hours urgent, 30 or 15 days pre-service and 60 or 30 days post-service; (i)(3)(i) and (f)(3) the 45-day clocks for disability claims; (m)(1) the definition of a claim involving urgent care; (l)(1) deemed exhaustion where a plan fails to follow its procedures (ecfr.gov/current/title-29/section-2560.503-1)
- Electronic Code of Federal Regulations — 29 CFR 2590.715-2719, Internal claims and appeals and external review processes: (b)(2)(ii)(E)(3)–(4) the denial notice must give the denial code and its meaning, the plan's standard, and the internal appeal and external review processes; (b)(2)(ii)(F)(1) failure to strictly adhere means the internal process is deemed exhausted; (c)(2)(vi) at least four months from receipt of the notice to request external review; (c)(2)(iv) the issuer pays for the independent reviewer and a state filing fee is capped at $25, refundable if reversed and waivable for hardship, with a $75 annual cap; (c)(2)(xii)–(xiii) 45 days for standard review and 72 hours for expedited; (d)(2)(i) the four-month request window and the rule for weekends and federal holidays; (d)(2)(iii)(B)(5) the reviewer decides de novo (ecfr.gov/current/title-29/section-2590.715-2719)
- Electronic Code of Federal Regulations — 45 CFR 147.136, the same framework applied to health insurance issuers offering group or individual coverage, including (c)(1) the substitution of a state external review process that meets the federal minimum standards (ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-147/section-147.136)
- U.S. Department of Labor, Employee Benefits Security Administration — Filing a Claim for Your Health Benefits: at least 180 days to request a full and fair review, the review decided by someone new who gives no consideration to the original decision, and the plan's obligation to provide relevant documents free of charge (dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-health-benefits)
- HealthCare.gov — Internal appeals and External review: the 180-day filing window, the 4-month external review request window, the 45-day and 72-hour decision clocks, and the list of denials eligible for external review (healthcare.gov/appeal-insurance-company-decision/)
- Medicare.gov — Filing an appeal: the separate Medicare appeal levels, the decision letter at each level, and the fast appeal available when covered services are ending too soon (medicare.gov/claims-appeals/how-do-i-file-an-appeal)