How to appeal a Marketplace health plan denial
The short answer
Marketplace plans give you 180 days from the day you get the denial to file an internal appeal, and they allow one level of internal appeal. If the insurer says no again, you have four months to ask for an independent external review, and the insurer must accept that reviewer’s decision.
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: 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: 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: 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. 45 CFR 147.136(b)(3)(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)(3)(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)(3)(ii)(F)(1)
- Keep ongoing treatment while you appeal. The insurer cannot cut off an approved ongoing course of treatment without advance notice and a chance to appeal first. 45 CFR 147.136(b)(3)(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. 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. 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 insurance you bought for yourself or your family through HealthCare.gov or a state marketplace, and for other individual plans bought directly from an insurer. The same federal rules cover both.
How the appeal works
- Internal appeal. You ask the insurer to review its decision. Individual plans get one level of internal appeal before a final decision (45 CFR 147.136(b)(3)(ii)(G)). The insurer has 30 days for care you haven’t had yet and 60 days for care you already received (HealthCare.gov).
- External review. If the insurer keeps its denial, you can ask an independent reviewer to look at it within four months. Your state runs this if its process meets federal standards; otherwise a federal process applies (HealthCare.gov).
When it can’t wait
If waiting could seriously harm your health, ask for an urgent review. The insurer must decide within 72 hours. In urgent cases you can also ask for an external review at the same time as the internal appeal (HealthCare.gov).
What external review can look at
HealthCare.gov lists three kinds of denial that can go to external review: any denial involving medical judgment where you or your provider disagree with the plan, any finding that a treatment is experimental or investigational, and cancellation of your coverage over information on your application (HealthCare.gov). The insurer is required by law to accept the reviewer’s decision.
Getting help
HealthCare.gov notes that the Consumer Assistance Program in your state can file an appeal for you (HealthCare.gov). CMS keeps a map of these programs.
Questions people ask
How long do I have to appeal a Marketplace denial?
180 days (6 months) from the day you receive the denial (HealthCare.gov).
How long does the insurer have to decide?
30 days for a service you haven’t received, 60 days for one you already received, and 72 hours when the case is urgent.
Is the external reviewer’s decision final?
For the insurer, yes: it must accept the decision (HealthCare.gov).
Sources
- HealthCare.gov: Internal appeals
You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.
- HealthCare.gov: External review
Your insurer is required by law to accept the external reviewer’s decision.
- eCFR: 45 CFR 147.136, Internal claims and appeals and external review processes
a health insurance issuer offering individual health insurance coverage must provide for only one level of internal appeal before issuing a final determination
- 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.