Getting a denial for a healthcare claim or pre-authorization request is frustrating — but it's not the final word. Federal laws — primarily ERISA and the ACA — lay out a clear, mandatory appeals process that health plans have to follow. Understanding that process helps you fight for the coverage you (or your employees) are entitled to. And the deadlines? They matter. Here's the standard internal and external appeals process and the timelines you need to know.
The Foundation: Your Plan Documents and ERISA Rights
First thing after a denial: review your Explanation of Benefits (EOB) or denial notice. By law, it must state the specific reason — "not medically necessary," "out of network," "experimental" — and explain your right to appeal. The real authority is your Summary Plan Description (SPD). That document spells out the plan's coverage rules and the formal appeals procedure. ERISA gives participants in employer-sponsored plans (except government or church plans) the right to a "full and fair review" of claim denials. Don't underestimate that right.
The Standard Two-Stage Appeals Process & Timelines
The ACA laid out a clear appeals process for most group health plans. The deadlines below are law for non-grandfathered plans, and most others follow similar rules. Here's what you're working with.
1. Internal Appeal (First Level)
You need to file a formal appeal with your health plan — in writing. You're asking them to take another look at their decision.
- Timeline to File: You have 180 days from the denial notice to submit your appeal. But check your SPD — some plans allow a shorter window.
- Plan's Decision Deadline: For urgent denials, the plan must decide within 72 hours. For pre-service denials (prior auth), they have 30 days. For post-service denials, 60 days.
- What to Gather: Evidence matters. Get a letter from your doctor explaining medical necessity, along with relevant clinical studies, peer-reviewed articles, and any evidence that counters the plan's denial reason.
2. External Review (Second Level)
If your internal appeal still gets denied, you can (in most cases) request an External Review. This is where an independent, third-party organization — not your health plan — makes a final, binding decision. It's your best shot if the plan plays hardball.
- Timeline to File: You have 4 months (120 days) from the final internal denial notice to request external review.
- Reviewer's Decision Deadline: For urgent cases, they decide within 72 hours. For standard cases, 45 days, with a possible 15-day extension in special circumstances.
- Binding Decision: The reviewer's decision is final and binds the plan. If they rule in your favor, the plan must approve coverage immediately.
Tips That Actually Work
- Act Fast. Put every deadline on your calendar. Miss one and you could lose your rights.
- Put It in Writing. Send everything by certified mail (or a method that gives proof of delivery). Keep a file with all correspondence, EOBs, and notes from phone calls — including rep names and dates.
- Get Your Doctor Involved. Your doctor is your best argument. They can write a detailed medical necessity letter that directly addresses the plan's denial reason.
- Cite Your Rights. In your appeals, reference ERISA and the ACA. It shows you know the law — and that you're serious.
- Consider a Lawyer. For high-cost or complex denials, an attorney who specializes in ERISA or insurance law can be a game-changer — especially if you eventually need to sue.
The Employer's Role: More Than Just Paperwork
For HR and benefits admins, making the appeals process run smoothly isn't just nice — it's a fiduciary duty under ERISA. Make sure your TPA or carrier meets every deadline and sends proper notices. Good documentation protects you from lawsuits and shows employees you've got their back. And tracking denial and appeal trends can reveal gaps in your plan design or vendor relationships — fixes you'll want to act on. WellthCare, the first Health-to-Wealth Benefit System, strengthens this process by embedding cost transparency tools, bill review, and compliance-grade recordkeeping directly into its platform, giving employers the data to fix gaps and employees a smoother path to coverage.
The appeals process has a clear structure — but it takes persistence. Know the deadlines, gather your evidence, and push back. A first denial doesn't have to be the last word.