Your deadline
For employer, marketplace and individual plans the appeal window after a denied reimbursement claim is the same 180 days from RECEIPT. The one that catches people first is different: your plan's TIMELY FILING limit for submitting the claim at all, which is set by the plan and is often far shorter. Find that number before anything else.
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.
Work out your own deadlineWhat to do
Find the timely-filing limit before you find anything else
This is the deadline that ends most reimbursement attempts, and it is not the same as an appeal deadline. It runs from the date of service, it is set by your plan rather than by law, and it can be as short as 90 days. Ask your plan in writing and put the answer in your calendar the same day.
Get an itemised superbill, not a receipt
A receipt proves you paid. A superbill proves what was done: the CPT codes, the ICD diagnosis codes, the date, the provider's NPI and tax ID, and the amount. A claim without codes cannot be processed. Ask the provider's billing office for a superbill by that name.
Ask the plan which form it wants, and where
Most plans have a member reimbursement claim form. Some accept the standard CMS-1500. Ask for the form and the address in the same message, send it so you can prove arrival, and keep a complete copy of everything you sent.
Say what authorisation you had, if you had any
If the care was authorised in advance, or approved as a gap exception, say so on the claim and attach the approval. A reimbursement claim that arrives with the authorisation already answered is much harder to deny for the reason it would otherwise be denied.
Treat a denied reimbursement claim as a denial, because it is
A refusal to reimburse is an adverse benefit determination like any other. The internal appeal, the external review and the deadlines all work the same way, and the pages on this site about appealing apply directly.
Check whether you should have been billed at all
On Medicaid especially, being billed may itself be the problem rather than the reimbursement being the answer. See the plan-type section below before you spend effort claiming money back you should never have paid.
Where the law is on your side, and where it is not
This is the part that differs most by plan type, and getting it wrong wastes months on the wrong argument.
- SELF-FUNDED PRIVATE EMPLOYER (ERISA): the claims regulation at 29 CFR 2560.503-1 covers post-service claims, so you have written reasons, the right to the documents relied on, a full and fair review, and a suit for benefits after exhausting the process. What it does NOT give you is a right to any particular amount for out-of-network care — that is the plan document, and a state insurance department has no authority here.
- FULLY INSURED EMPLOYER, AND MARKETPLACE OR INDIVIDUAL: the same federal claims floor applies, and you ALSO have a state regulator who can act on it. That second route is the real difference. State prompt-pay rules and state coverage mandates can reach your plan where they cannot reach a self-funded one.
- CHURCH, GOVERNMENT AND SCHOOL-DISTRICT PLANS: outside ERISA, so the Department of Labor route does not exist and the plan document does more of the work. Ask the plan, in writing, what its reimbursement and appeal process is, and keep the answer — you may be the only person holding it in writing.
- MEDICAID: this is where the law is most protective and least about reimbursement. Providers who accept Medicaid generally may not bill an enrollee for a covered service, so if you were charged, the question is usually whether you should have been billed at all rather than how to claim it back. Take that to your state Medicaid agency, not to a reimbursement form.
- MEDICARE: providers are generally required to submit claims for covered services rather than leaving it to you, and there is a route to file yourself if one will not. The deadline is fixed and generous compared with commercial plans — one calendar year from the date of service, 42 CFR 424.44(a)(1).
The situations where nothing helps, said plainly
If the service is genuinely excluded by your plan and the exclusion is lawful for your plan type, no reimbursement claim reaches it. The argument there is about the exclusion, not about the receipt.
If you paid cash at a provider who never generates a claim and cannot produce codes, there may be nothing to submit. Ask before the appointment rather than afterwards; a provider who will not produce a superbill is a provider whose care you are paying for entirely yourself, and that is worth knowing on the day rather than in six months.
If the timely-filing limit has passed, the plan will usually say so and stop. It is sometimes worth arguing that the delay was the plan's own doing — a lost authorisation, a claim it never acknowledged — but that is an argument about the plan's conduct rather than about the care, and it needs the dates and the call log to make.
Common questions
- I paid for surgery out of network. Can I get anything back?
- It depends on whether your plan has an out-of-network benefit at all. A PPO usually does, at a worse rate. An EPO or HMO usually does not, except in an emergency, and there the argument is a network-adequacy one made before you pay rather than a reimbursement one made after. Read the network section on the gap-exception page.
- Does an approval mean I will be reimbursed in full?
- No. An authorisation says the plan agrees the service is covered. What you are paid depends on the plan's allowed amount, your deductible and coinsurance, and whether the provider was in network. Those are separate questions and it is worth asking all three in writing before the date.
- My electrologist does not take insurance. Is there anything to claim?
- Usually yes, by superbill: you pay, they give you the itemised bill described above, and you file it yourself as an out-of-network claim. Check whose NPI goes on it before you book. An electrologist working inside a clinic can often be billed for under a supervising nurse practitioner or physician, in which case the claim may go in directly and you may not need to pay up front at all. Someone working independently usually has no NPI of their own, and a superbill without a billable provider's number cannot be processed.
- How long should reimbursement take?
- Ask your plan for its stated turnaround and hold it to that in writing. If it passes without a decision, that silence is itself something you can escalate, and on a state-regulated plan your insurance department may have a prompt-pay rule that applies.
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
Also on this page, without a citation yet
- That an electrologist's work can be billed under a supervising nurse practitioner or physician. Medicare's incident-to rule at 42 CFR 410.26 is built this way and many commercial plans mirror it, but a commercial plan is not bound by that regulation and its own provider manual governs. Ask your plan and ask the clinic.
- Your plan's timely-filing limit for submitting a claim, if you are NOT on Medicare. It is set by the plan document, commonly between 90 days and a year from the date of service, and no federal rule fixes it for commercial plans. This is the deadline that quietly ends most reimbursement attempts, and it is not the appeal deadline. Ask your plan in writing. (Medicare's own limit IS fixed: one calendar year, 42 CFR 424.44(a)(1).)
- The mechanics of filing a Medicare claim yourself when a provider will not — which form, and where it goes. The DEADLINE is verified: 42 CFR 424.44(a)(1) gives one calendar year from the date of service. Call 1-800-MEDICARE for the form.
- State prompt-pay laws and any state requirement to reimburse. These are state law, they vary widely, and your state insurance department is the authority.
These are specific and checkable and we have not yet checked them against a primary source. Treat them as a starting point rather than as settled, and do not put them in an appeal without confirming them.