How to appeal a denial from an employer health plan
The short answer
If your insurance comes through a job, federal rules give you at least 180 days from the day you get the denial to file an internal appeal. If the plan says no again and the denial involved a medical judgment, you can usually ask for an independent external review within four months.
Deadlines, decision times and your rights
These are the limits in the federal rules. Your plan can give you more time but not less. If your denial letter prints an earlier date, go by the earlier one.
Deadline to appeal
180 days from the day you receive the denial notice
Rule: 29 CFR 2560.503-1(h)(3)(i)
What the rule says
Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination;
How long they have to decide
72 hours after the plan receives your urgent appeal
Rule: 29 CFR 2560.503-1(i)(2)(i)
What the rule says
In the case of a claim involving urgent care, the plan administrator shall notify the claimant, in accordance with paragraph (j) of this section, of the plan's benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claimant's request for review of an adverse benefit determination by the plan.
30 days after the plan receives your appeal
Rule: 29 CFR 2560.503-1(i)(2)(ii)
What the rule says
In the case of a group health plan that provides for one appeal of an adverse benefit determination, such notification shall be provided not later than 30 days after receipt by the plan of the claimant's request for review of an adverse benefit determination.
60 days after the plan receives your appeal
Rule: 29 CFR 2560.503-1(i)(2)(iii)(A)
What the rule says
In the case of a group health plan that provides for one appeal of an adverse benefit determination, such notification shall be provided not later than 60 days after receipt by the plan of the claimant's request for review of an adverse benefit determination.
45 days after the independent reviewer receives your request
Rule: 29 CFR 2590.715-2719(d)(2)(iii)(B)(6)
What the rule says
The assigned IRO must provide written notice of the final external review decision within 45 days after the IRO receives the request for the external review.
72 hours after the independent reviewer receives your urgent request
Rule: 29 CFR 2590.715-2719(d)(3)(iv)
What the rule says
The plan's or issuer's contract with the assigned IRO must require the IRO to provide notice of the final external review decision, in accordance with the requirements set forth in paragraph (d)(2)(iii)(B) of this section, as expeditiously as the claimant's medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review.
45 days after the independent reviewer receives your request
Rule: 45 CFR 147.136(d)(2)(iii)(B)(6)
What the rule says
The assigned IRO must provide written notice of the final external review decision within 45 days after the IRO receives the request for the external review.
72 hours after the independent reviewer receives your urgent request
Rule: 45 CFR 147.136(d)(3)(iv)
What the rule says
The plan's or issuer's contract with the assigned IRO must require the IRO to provide notice of the final external review decision, in accordance with the requirements set forth in paragraph (d)(2)(iii)(B) of this section, as expeditiously as the claimant's medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review.
The next level
4 months after you receive the final denial
Rule: 29 CFR 2590.715-2719(d)(2)(i)
What the rule says
A group health plan or health insurance issuer must allow a claimant to file a request for an external review with the plan or issuer if the request is filed within four months after the date of receipt of a notice of an adverse benefit determination or final internal adverse benefit determination. If there is no corresponding date four months after the date of receipt of such a notice, then the request must be filed by the first day of the fifth month following the receipt of the notice. For example, if the date of receipt of the notice is October 30, because there is no February 30, the request must be filed by March 1. If the last filing date would fall on a Saturday, Sunday, or Federal holiday, the last filing date is extended to the next day that is not a Saturday, Sunday, or Federal holiday.
4 months after you receive the final denial
Rule: 45 CFR 147.136(d)(2)(i)
What the rule says
A group health plan or health insurance issuer must allow a claimant to file a request for an external review with the plan or issuer if the request is filed within four months after the date of receipt of a notice of an adverse benefit determination or final internal adverse benefit determination. If there is no corresponding date four months after the date of receipt of such a notice, then the request must be filed by the first day of the fifth month following the receipt of the notice. For example, if the date of receipt of the notice is October 30, because there is no February 30, the request must be filed by March 1. If the last filing date would fall on a Saturday, Sunday, or Federal holiday, the last filing date is extended to the next day that is not a Saturday, Sunday, or Federal holiday.
At least 4 months after you receive the denial; your state may allow longer
Rule: 29 CFR 2590.715-2719(c)(2)(vi)
What the rule says
The State process must allow at least four months after the receipt of a notice of an adverse benefit determination or final internal adverse benefit determination for a request for an external review to be filed.
At least 4 months after you receive the denial; your state may allow longer
Rule: 45 CFR 147.136(c)(2)(vi)
What the rule says
The State process must allow at least four months after the receipt of a notice of an adverse benefit determination or final internal adverse benefit determination for a request for an external review to be filed.
Your rights along the way
- Get free copies of your claim file. You can ask for every document used in your claim, free of charge. 29 CFR 2560.503-1(h)(2)(iii)
- What counts as a 'relevant' document you can get. Relevant documents include anything the plan relied on, considered or generated, plus its policy on your treatment. 29 CFR 2560.503-1(m)(8)
- Plan must tell you the specific reason for the denial. The denial notice must state the specific reasons and the plan provisions it relied on. 29 CFR 2560.503-1(g)(1)(i)-(ii)
- Get the internal rule or guideline used to deny you. If the plan used an internal rule, guideline or protocol, it must give it to you or offer it free. 29 CFR 2560.503-1(g)(1)(v)(A)
- Get the medical reasoning behind a 'not medically necessary' denial. For medical-necessity or experimental denials, the plan must explain its clinical judgment applied to your case, free on request. 29 CFR 2560.503-1(g)(1)(v)(B)
- You can request an urgent appeal by phone. Urgent appeals can be made orally or in writing; the plan must use phone, fax or similar fast methods. 29 CFR 2560.503-1(h)(3)(vi)
- Your appeal must be a fresh review by someone new. The appeal reviewer may not defer to the first denial and cannot be the person (or their subordinate) who denied you. 29 CFR 2560.503-1(h)(3)(ii)
- Present evidence and testimony; review your claim file. You may review the claim file and present evidence and testimony in your appeal. 29 CFR 2590.715-2719(b)(2)(ii)(C)
- Your doctor decides whether your appeal is urgent. If your treating provider says the claim is urgent, the plan must treat it as urgent. 29 CFR 2590.715-2719(b)(2)(ii)(B)
- If the plan breaks the appeal rules, you can skip ahead. If the plan does not follow the claims-and-appeals rules, you may go straight to external review (or court). 29 CFR 2590.715-2719(b)(2)(ii)(F)(1)
- Present evidence and testimony; review your claim file. You may review the claim file and present evidence and testimony in your appeal. 45 CFR 147.136(b)(2)(ii)(C)
- Your doctor decides whether your appeal is urgent. If your treating provider says the claim is urgent, the plan must treat it as urgent. 45 CFR 147.136(b)(2)(ii)(B)
- If the plan breaks the appeal rules, you can skip ahead. If the plan does not follow the claims-and-appeals rules, you may go straight to external review (or court). 45 CFR 147.136(b)(2)(ii)(F)(1)
- Keep ongoing treatment while you appeal. The plan cannot cut off an approved ongoing course of treatment without advance notice and a chance to appeal first. 29 CFR 2590.715-2719(b)(2)(iii)
- Keep ongoing treatment while you appeal. The plan cannot cut off an approved ongoing course of treatment without advance notice and a chance to appeal first. 45 CFR 147.136(b)(2)(iii)
- Surprise-billing disputes qualify for external review. Denials about No Surprises Act protections (emergency, out-of-network at in-network facility, air ambulance) can go to external review. 29 CFR 2590.715-2719(d)(1)(i)(B)
- Surprise-billing disputes qualify for external review. Denials about No Surprises Act protections (emergency, out-of-network at in-network facility, air ambulance) can go to external review. 45 CFR 147.136(d)(1)(i)(B)
- Emergency care needs no prior approval, even out of network. Your plan cannot deny emergency care for lack of prior authorization or because the ER was out of network. 29 CFR 2590.716-4(b)(1)
- Emergencies are judged by a reasonable person's view of your symptoms. An emergency is defined by symptoms a prudent layperson would think need immediate care, not by the final diagnosis. 29 CFR 2590.716-4(c)(1)
- Emergency care needs no prior approval, even out of network. Your plan cannot deny emergency care for lack of prior authorization or because the ER was out of network. 45 CFR 149.110(b)(1)
- Emergencies are judged by a reasonable person's view of your symptoms. An emergency is defined by symptoms a prudent layperson would think need immediate care, not by the final diagnosis. 45 CFR 149.110(c)(1)
Each rule links to its text in the Electronic Code of Federal Regulations. Checked against the regulation text on November 10, 2026. The Lamdis app works out your dates from these same rules.
Is this your plan?
This page is for coverage you or a family member get through work, including COBRA. Most private employer plans follow the federal claims rules in 29 CFR 2560.503-1. If you work for a state or local government or a church, your plan may use a different process, so follow the appeal instructions printed in your denial letter.
Plans that have stayed the same since before March 23, 2010, called grandfathered plans, can be exempt from some of the newer appeal rules. CMS describes the external appeal rights as covering plans created after that date.
Self-funded or fully insured: why it matters
Some employers, often large ones, pay claims with their own money and hire an insurance company only to run the plan. These are called self-funded or self-insured plans. Others buy a policy from an insurer.
The difference decides who handles external review. When the employer bought insurance, the insurer follows your state’s external review process if that process meets federal standards. A self-funded plan usually uses the federal external review process instead (29 CFR 2590.715-2719(c)(1)). Your Summary Plan Description or your HR benefits team can tell you which kind you have.
What external review covers
An external review is decided by an independent review organization, and the plan must accept its decision (HealthCare.gov). Under the federal process it covers denials that involve medical judgment, such as medical necessity, level of care or a finding that a treatment is experimental; denials under the surprise-billing protections; and cancelled coverage (29 CFR 2590.715-2719(d)(1)(i)).
A denial that turns only on what the plan document covers, with no medical judgment involved, may fall outside federal external review. See when the plan says it isn’t covered.
If the plan breaks the rules
If the plan does not strictly follow the internal appeal rules for your claim, you are treated as having finished the internal appeal and can go straight to external review (29 CFR 2590.715-2719(b)(2)(ii)(F)(1)). Small slip-ups that did not harm you do not count.
What to send
- A short letter that names the claim number and says you are appealing.
- The reason the denial is wrong, tied to your records and the plan’s own wording.
- A letter of medical necessity from your doctor when the denial is about medical need.
- Copies of anything the plan said was missing.
Keep a copy of everything and a record of the date and how you sent it.
Questions people ask
How long do I have to appeal an employer plan denial?
At least 180 days from the day you receive the denial. Your plan can give you longer but cannot give you less (29 CFR 2560.503-1(h)(3)(i)). Check the denial letter for the exact date your plan uses.
Can my plan have two levels of appeal?
Yes. Some employer plans have two internal levels. Each level then has a shorter decision time: for care you haven’t had yet, 15 days per level instead of 30 (29 CFR 2560.503-1(i)(2)(ii)).
Does state insurance law apply to my employer plan?
It depends on whether the plan is fully insured or self-funded. Ask HR or check the Summary Plan Description. Our state pages explain each state’s external review process and who it covers.
Who can help me for free?
Many states run a Consumer Assistance Program that helps people with insurance problems (CMS list of programs).
Sources
- eCFR: 29 CFR 2560.503-1, Claims procedure
Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination
- eCFR: 29 CFR 2590.715-2719, Internal claims and appeals and external review processes
the claimant is deemed to have exhausted the internal claims and appeals process
- HealthCare.gov: External review
Your insurer is required by law to accept the external reviewer’s decision.
- CMS: External Appeals
consumers have the right to appeal decisions made by health plans created after March 23, 2010
- CMS: Consumer Assistance Program
Many states offer help to consumers with health insurance problems through Consumer Assistance Programs
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.