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How a health insurance appeal actually works, start to finish

An appeal has three stages: an internal appeal decided by the plan, an external review decided by an independent organization, and, if the plan misses its own deadlines, deemed exhaustion that lets you skip ahead. For employer and marketplace plans the floor is 180 days, counted from when the notice reached you.

Applies to Employer, marketplace and individual plans. Every other kind of coverage runs its own appeal process on its own clock, and the deadline block below says which one is yours.

Your deadline

For employer, marketplace and individual plans: at least 180 days from RECEIPT for the internal appeal, then four months from the final internal denial for external review. Both count from when the notice reached you. Medicaid and Medicare run on different, shorter clocks — see below.

This is not everyone’s clock. Medicaid or CHIP, Medicare, TRICARE, VA health care and a church or government employer plan run on different rules. Do not assume the number above is yours.

Medicaid or CHIPMedicareTRICAREVA health carea church or government employer plan
Work out your own deadline
See your insurer's complaint recordA complaint to the insurance department runs alongside an appeal and goes over your plan's head. Whether it is worth the afternoon depends on the company.

What to do

  1. Find the three dates on your denial letter

    The date of the decision, the date you received it, and the deadlines to appeal. The federal rule gives you at least 180 days from RECEIPT of the notice, not from the date printed on it — but plans count differently, so work from the earlier date and you are always safe.

  2. Request the file

    Ask in writing for every document, internal rule, guideline, and clinical criterion the plan relied on. You are entitled to it, and it is usually free.

  3. If the denial was clinical, ask about a peer-to-peer BEFORE you file

    A peer-to-peer is a call between your clinician and the plan's reviewing doctor, and most plans stop offering it once an appeal is filed. It can reverse the decision without spending a level of appeal, so the order matters. Ask what your plan's process is, and keep counting your deadline while you wait.

  4. File the internal appeal

    Answer the specific reason given. Attach clinical documentation that speaks to the plan's own stated criteria.

  5. Ask for an expedited appeal if delay would harm you

    Expedited timelines are much shorter. If waiting means losing a surgical date or interrupting care, say so explicitly and ask in writing — and get your clinician to say it. Under 29 CFR 2560.503-1(m)(1)(iii), any claim a physician with knowledge of your condition determines is urgent SHALL BE TREATED as urgent. Without that determination the plan applies a prudent-layperson test itself under (m)(1)(ii); with it, the plan does not get to substitute its own view.

  6. Request external review after the internal appeal fails

    An independent review organization looks at the file. Its decision binds the plan.

  7. Use deemed exhaustion if the plan blows its own deadlines

    If the plan does not follow the required process, you may be able to treat the internal process as exhausted and proceed without waiting.

Write down everything, from the first call

Date, time, the name of the person you spoke to, a reference number, and what they said. Appeals are decided on records. The plan has one of every call; if you do not, disagreements about what you were told resolve in their favor by default.

Common questions

How long do I have to file an internal appeal?
For an employer, marketplace or individual plan: at least 180 days, counted from when you received the notification, under 29 CFR 2560.503-1(h)(3)(i). Your plan may give more but not less. This does NOT apply to Medicaid or Medicare. Medicaid managed care allows 60 calendar days from the date on the notice (42 CFR 438.402(c)(2)(ii)); Medicare redetermination is 120 days. Working from the date printed on the letter rather than the day it arrived gives you a safety margin.
Is external review binding?
Yes. Under 29 CFR 2590.715-2719(d)(2)(iv) the plan must immediately provide coverage or payment on reversal — immediately authorizing care or immediately paying benefits. The state-process equivalent at (c)(2)(xi) requires benefits without delay.
What is deemed exhaustion?
When a plan fails to follow the required claims and appeals process, you may be treated as having exhausted the internal process, which unlocks the next step early.

Where to go next

Sources for the legal points on this page

If a treating physician says the claim is urgent, the plan must treat it as urgent

Federal — ERISA-governed group health plans · effective in force

29 CFR 2560.503-1(m)(1)(iii) (physician determination controls), read against (m)(1)(ii) (otherwise a prudent-layperson standard applied by the plan) and (m)(1)(i) (what makes a claim urgent)

Status: settled · source-checked 2026-08-09 · primary source verified: 2026-08-09 (govinfo CFR XML, 2025 edition)

The ACA appeal framework: internal appeal, then binding external review

Federal — non-grandfathered group health plans and issuers · effective in force

29 CFR 2590.715-2719 — (b)(2)(ii)(B) urgent-care 72 hours, (b)(2)(ii)(F)(1) deemed exhaustion, (c)(2)(xi) state external review binding, (d)(2)(i) four-month federal external review window, (d)(2)(iv) immediate coverage on reversal; 29 CFR 2560.503-1 — (c)(2) no more than two appeals before civil action, (h)(3)(i) 180 days from receipt, (h)(3)(ii) independent reviewer, (h)(3)(iii) health professional on medical judgment

Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06

Last updated 2026-08-09Not legal or medical advice