Your deadline
At least 180 days from RECEIPT of the denial. WHICH RULE gives you that depends on where the policy came from: for employer-sponsored coverage it is the DOL claims regulation, 29 CFR 2560.503-1(h)(3)(i); for a policy you bought yourself it is the HHS side, 45 CFR 147.136, which sets these requirements for health insurance issuers. A plan you bought on the marketplace is NOT an ERISA plan, so citing the DOL rule at your insurer is citing the wrong regulator. External review is four months from the final internal denial either way.
What to do
Confirm the plan is fully insured
Ask HR, or look for a state insurance-department marking on the card. Some states require one and the format differs by state, so if you cannot find one the generic method is better anyway: call the number on the card and ask, in these words, whether the plan is fully insured or self-funded — then ask them to confirm it in writing or in a portal message, because the answer decides which regulator can help you and you may need to show it.
Get the Evidence of Coverage
This is the fully insured equivalent of a plan document. It states the covered benefits, the exclusions, and the appeal deadlines.
Check whether a state mandate covers the care
State mandates reach insurers, so they reach this plan. If your state requires coverage, an exclusion in the policy may be unenforceable.
File the internal appeal
At least 180 days from receipt under the federal floor; your policy may allow more. Attach the clinical documentation the denial says is missing, and address the specific criterion the insurer named.
Request external review when the internal appeal fails
An independent organization reviews the file. The decision binds the insurer. This is the step that most often reverses a medical-necessity denial.
File a complaint with the state insurance department in parallel
It costs nothing, it creates a regulatory record, and in some states it is what finally moves the file.
Why fully insured is the strongest position
You have three separate levers instead of one: the plan's own internal process, a binding external review by people who do not work for the insurer, and a regulator with authority over the company. On a self-funded plan the third lever does not exist.
Common questions
- What does CO-DOI on my card mean?
- It marks a plan regulated by that state's insurance department, which means the state's nondiscrimination rules and coverage requirements apply to it. Your own department is listed on the states page.
- Is the external reviewer really independent?
- Yes. External review is conducted by an independent review organization; the insurer does not choose the outcome and is bound by the decision.
Where to go next
Sources for the legal points on this page
- Individual-market appeals run through the HHS rule, not the DOL one
Federal — individual and group health insurance issuers · effective in force
45 CFR 147.136 (internal claims and appeals and external review processes, group health plans AND health insurance issuers)
Status: settled · source-checked 2026-08-08 · primary source verified: 2026-08-08
- 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