What to do
First: is your coverage not through a job at all?
The three steps after this one assume an employer, and for a lot of people that is the wrong tree. If you get care through the VA as a veteran, or your coverage is TRICARE because you serve or served or are a military family member, or it is Medicaid, CHIP or Medicare, then you already know your plan type and you can skip straight to your own page below. Those four run on their own statutes, and nothing about employer plans applies to them.
Ask your employer one question
If you get coverage through work: ask HR or benefits whether the plan is self-funded or fully insured. Then ask who the employer is — a private company, or a government body, school district, public university, or church. Both answers matter.
Look at your insurance card
A state insurance-department marking on the card points to a state-regulated plan. The format differs by state and many cards carry none, so its absence is a hint, not proof.
Check the Summary Plan Description or Evidence of Coverage
Employer plans that are self-funded usually say so. This document also carries your deadlines.
Then read the page for your plan type
The links below are not variations on the same advice. They are different laws, different regulators, and different clocks. Two forks catch people out. Self-funded splits in two: private employers are ERISA, while state and local government, school district, church and federal CIVILIAN employers are not. And military coverage is not an employer plan at all — TRICARE and the VA are separate statutory systems with their own pages.
Why this fork comes first
People lose months arguing with a regulator who has no authority over their plan. Someone on a self-funded employer plan files a complaint with their state insurance department; the state returns it, because a self-funded plan is not insurance and the state cannot touch it. Meanwhile the appeal deadline runs.
Nothing else on this site is more valuable than getting this right in the first ten minutes.
Common questions
- What if my employer will not tell me?
- Request the Summary Plan Description in writing. For an ERISA plan you have a right to it, and it will identify the plan's funding.
- What if I have more than one kind of coverage?
- Work out which plan is being billed for the service that was denied. That plan's rules govern that denial.