What to do
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.
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.
File the internal appeal
Answer the specific reason given. Attach clinical documentation that speaks to the plan's own stated criteria.
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.
Request external review after the internal appeal fails
An independent review organization looks at the file. Its decision binds the plan.
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 favour by default.
Common questions
- How long do I have to file an internal appeal?
- At least 180 days, counted from when you received the notification. That is the federal floor under 29 CFR 2560.503-1(h)(3)(i); your plan may give more but not less. 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 authorising 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
- 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