Health Insurance Denial Appeal Deadlines
When a health plan denies a claim, the clock starts on the date you receive the denial notice. Federal rules set minimum timelines for the plan and for you: how long you have to appeal, how quickly the plan must answer, and how long you have to ask for an independent external review. This page summarizes those federal minimums for private health plans. State law can add protections for insured (non-self-funded) plans, and Medicare and Medicaid have their own appeal rules that are not covered here.
Your denial letter and plan documents control the exact dates that apply to you. Check them first, and write down the date you received the denial.
| Step | Timeline | Source |
|---|---|---|
| File your internal appeal | The plan must give you at least 180 days after you receive the denial notice | 29 CFR § 2560.503-1(h)(3)(i) |
| Plan decides an urgent-care claim | As soon as possible, and no later than 72 hours after it receives the claim | 29 CFR § 2560.503-1(f)(2)(i) |
| Plan decides a pre-service claim (before you get care) | Within 15 days, with one extension of up to 15 days for reasons outside the plan’s control | 29 CFR § 2560.503-1(f)(2)(iii) |
| Plan decides a post-service claim (after you got care) | Within 30 days, with one extension of up to 15 days for reasons outside the plan’s control | 29 CFR § 2560.503-1(f)(2)(iii) |
| Plan decides your appeal: urgent care | No later than 72 hours after it receives your appeal | 29 CFR § 2560.503-1(i)(2)(i) |
| Plan decides your appeal: pre-service | No later than 30 days after it receives your appeal, for a plan with one level of appeal | 29 CFR § 2560.503-1(i)(2)(ii) |
| Plan decides your appeal: post-service | No later than 60 days after it receives your appeal, for a plan with one level of appeal | 29 CFR § 2560.503-1(i)(2)(iii) |
| Request external review | Within 4 months after you receive the denial or final internal denial notice | 45 CFR § 147.136(d) |
| Independent reviewer (IRO) decides | Within 45 days after the IRO receives the request for standard external review | 45 CFR § 147.136(d) |
| Expedited external review | As expeditiously as possible, and no more than 72 hours after the IRO receives the request | 45 CFR § 147.136(d) |
Which rules apply to your plan
The Affordable Care Act regulation at 45 CFR § 147.136 requires group health plans and insurers offering group or individual coverage to run an effective internal claims and appeals process and to provide external review (§ 147.136(b)). For group plans, that internal process builds on the Department of Labor claims regulation for ERISA plans at 29 CFR § 2560.503-1, which is where the 180-day and decision-deadline rules in the table come from.
Grandfathered plans are generally outside most of § 147.136, but the external review requirements still apply to them for disputes over certain out-of-network emergency services, nonemergency services by out-of-network providers at in-network facilities, and air ambulance services (§ 147.136(a)(1)(ii)).
ERISA plans (most job-based coverage) and insured plans can be reviewed differently on the external-review step. Where a state external review process meets the federal minimum standards, the state process applies; a plan or insurer not subject to one must provide the federal process (§ 147.136(c) and (d)).
Internal appeal first
Start with the internal appeal. Under the ERISA claims rule, the plan must give you at least 180 days after the denial notice to appeal, a review that does not defer to the original decision, and the chance to submit written comments, documents and other information (29 CFR § 2560.503-1(h)(2)(ii), (h)(3)(i) and (h)(3)(ii)).
You can ask the plan for reasonable access to, and copies of, all documents, records and other information relevant to your claim, free of charge (29 CFR § 2560.503-1(h)(2)(iii)). Ask for the claim file in your first letter so you can answer the stated reason for denial point by point.
If a plan does not follow the internal appeal rules, you may be deemed to have exhausted the internal process and can move to external review or other remedies (45 CFR § 147.136(b)(2)(ii)(F)).
Then external review
If the internal appeal fails, you can ask for review by an independent review organization. Under the federal process, the request must be filed within four months after you receive the denial or the final internal denial (45 CFR § 147.136(d)). The IRO decides standard requests within 45 days of receiving them and expedited requests within 72 hours (45 CFR § 147.136(d)).
Expedited external review is available when the standard time frame would seriously jeopardize your life or health or your ability to regain maximum function, and in certain emergency situations before discharge (45 CFR § 147.136(d)).
Write my health insurance appeal letter
Answer a few questions and get a ready-to-send appeal letter for $19.
Write my health insurance appeal letter →