Under the Affordable Care Act, a denied health insurance claim can go through two stages: an internal appeal, where the plan reviews its own decision, and an external review, where an independent reviewer decides. HealthCare.gov states that an internal appeal must be filed "within 180 days (6 months) of receiving notice that your claim was denied," and that an external review request must be filed in writing "within 4 months after the date you receive a notice or final determination." Which agency oversees each stage depends on the kind of plan, and that is the question most appeal guides skip.
This article relays how federal agencies describe the appeal process in the United States. It is general information, not legal, medical, insurance or financial advice. It makes no judgment about whether any particular denial is correct or worth appealing. Your plan documents, your plan's member services and the regulators named below are the authorities for your own claim.
Sources read September 11, 2026. Deadlines and timeframes below are quoted from the agency pages named in each sentence. Some plans, including grandfathered plans and government programs, follow different rules.
How to appeal a denied health insurance claim: the two stages
HealthCare.gov's page on appealing an insurance company decision, read September 11, 2026, describes the structure in two sentences. First: "If your claim is denied or your health insurance coverage canceled, you have the right to an internal appeal." Second: "You have the right to take your appeal to an independent third party for review. This is called an external review."
The second stage is the one with teeth. HealthCare.gov puts it plainly: with external review, "the insurance company no longer gets the final say over whether to pay a claim."
The sequence usually runs in this order:
- The plan issues a denial notice that states its reason.
- The member, often with the provider's office, files an internal appeal with the plan.
- The plan decides the internal appeal within a federal timeframe.
- If the plan upholds its denial, the member may request an external review by an independent reviewer.
Step 1: Read the denial notice before anything else
The notice is the starting document for everything that follows. It states what was denied, the reason, and the deadline and method for appealing. For services already received, the denial often shows up first on the explanation of benefits, and our walkthrough of how to read an explanation of benefits, line by line covers where the reason codes and remark codes sit on that page.
It also matters which document is in hand. A provider's bill and a plan's EOB are different papers that arrive at different times, and an appeal is filed against the plan's decision, not against the bill. Our comparison of an EOB and a medical bill sets out how to tell them apart.
HealthCare.gov's internal appeals page, read September 11, 2026, gives the timeframes within which a plan must tell a member that a claim was denied: "Within 15 days if you're seeking prior authorization for a treatment," "Within 30 days for medical services already received," and "Within 72 hours for urgent care cases."
Step 2: The internal appeal
The internal appeal asks the plan to take a second look at its own decision. HealthCare.gov describes it as a request that the insurer "conduct a full and fair review of its decision."
The deadline. HealthCare.gov states that the internal appeal must be filed "within 180 days (6 months) of receiving notice that your claim was denied." The Department of Labor, writing about employer plans, phrases the same rule as "You have at least 180 days to file an appeal." The words "at least" matter: a plan may allow more time, and the plan's own notice states its deadline.
What goes in. HealthCare.gov describes completing the insurer's forms, or writing to the insurer with the member's name, claim number and health insurance ID number, and submitting "any additional information that you want the insurer to consider, such as a letter from the doctor."
The National Association of Insurance Commissioners, in a consumer article dated August 17, 2020 and read September 11, 2026, on how to appeal a denied health claim, adds practical record-keeping points. It lists gathering "your policy, the Summary of Benefits Coverage (SBC), and your denial letter," to "keep notes of all conversations you have with company representatives," and to "keep copies of everything you send to the insurance company for your records." On the content of an appeal letter, it describes giving "specific reasons why your claim should be paid under your policy" and including supporting evidence such as records or a letter from the treating physician.
The right to the file. For employer plans, the Department of Labor's publication on filing a claim for your health benefits, read September 11, 2026, states: "The plan must provide you copies of documents, records, and other information relevant to your claim for free if you request them."
The decision timelines, side by side
Two federal sources describe how long the plan has to decide an internal appeal. Their numbers line up, and seeing them together makes the pattern clear.
| Situation | HealthCare.gov (internal appeals page) | Department of Labor (employer plans) |
|---|---|---|
| Service not yet received (pre-service) | "within 30 days" | "no more than 30 days" |
| Service already received (post-service) | "within 60 days" | "no more than 60 days" |
| Urgent care | Expedited; final decision "at least within 4 business days" | "no more than 72 hours" |
| Filing window for the member | 180 days from the denial notice | "at least 180 days" |
Both pages read September 11, 2026. The two agencies describe urgent timing differently, and the plan's own notice states which rule it follows.
The honest limit of this table: it is the federal floor. Plans can decide faster, states can set their own rules for the plans they regulate, and the plan document is where the plan's actual commitments are written.
Step 3: External review
HealthCare.gov's external review page, read September 11, 2026, sets out the second stage.
When it opens. "If your insurance company still denies you the service or payment for a service, you can ask for an external review." The request must be written and filed "within 4 months after the date you receive a notice or final determination."
What it decides. "An external review either upholds your insurer's decision or decides in your favor." And the outcome binds the plan: "Your insurer is required by law to accept the external reviewer's decision."
How long it takes. "Standard external reviews are decided as soon as possible, no later than 45 days after the request was received." Expedited reviews are decided "no later than 72 hours, or less, depending on the medical urgency."
What it costs. HealthCare.gov states that under the HHS-administered federal external review process "there's no charge," and that where another process is used, a charge cannot exceed $25 per review.
Which denials qualify. This is where many readers get surprised. HealthCare.gov lists denials involving medical judgment, denials on the ground that a treatment is experimental or investigational, and cancellations of coverage based on a claim that the application contained false or incomplete information. A denial about something else, for example whether a person was enrolled at all, may not fit those categories, and the notice or the regulator can say whether external review is available.
Who runs it. Depending on the state and the plan, the external review may be run by the state, by the federal Department of Health and Human Services, or through an independent review organization the plan contracts with.
When the situation is urgent
Both stages have a fast track. HealthCare.gov describes an expedited appeal where "the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function." It also notes: "If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal." The NAIC describes asking the plan to expedite when the member or the doctor believes a denial could be life-threatening. Whether a situation meets that standard is a clinical judgment that belongs to the treating clinician, not to an article.
Which rulebook governs your plan, and who to call
Most appeal guides stop after the steps. The more useful question is which regulator stands behind them, because that decides who answers the phone when a plan misses a deadline or refuses to cooperate.
| If the coverage is… | Main rules described by | Who a member can contact |
|---|---|---|
| An individual or family plan, including a Marketplace plan | HealthCare.gov internal appeals and external review pages | The state Department of Insurance; the plan's notice names the external review route |
| A fully insured employer plan | Department of Labor claims rules plus state insurance law | The Department of Labor's EBSA and the state Department of Insurance |
| A self-funded employer plan | Department of Labor claims rules (ERISA) | EBSA, which the Department of Labor lists at 1-866-444-3272 |
| A grandfathered plan | Plan terms; the Department of Labor notes that external review is required of plans "not grandfathered under the Affordable Care Act" | The plan administrator, then EBSA or the state regulator |
| Medicare or Medicaid | Separate program rules, not covered here | Medicare at 1-800-MEDICARE; Medicaid through the state Medicaid agency |
Whether an employer plan is fully insured or self-funded is stated in the plan's Summary Plan Description, and the employer's benefits office can confirm it. The NAIC's advice for insured plans is short: "Contact your state Department of Insurance if you feel your insurer is not cooperating."
Some denials trace to network status rather than medical judgment. Where that is the stated reason, the plan's network rules are the starting point, as set out in our guide to in-network and out-of-network allowed amounts, and the records a member kept when checking whether a doctor was in network can become part of the appeal file.
What this article cannot tell you
It cannot tell you whether a denial is right. It cannot say whether an appeal will succeed, what a plan document means for a specific claim, or which deadline applies to a plan that follows state rules or its own longer timeframes. The Department of Labor notes that a person "may decide to seek legal advice if your claim's appeal is denied or if the plan failed to establish or follow reasonable claims procedures," and a licensed attorney is the professional for that question.
What the regulators need from a reader who calls: the denial notice, the claim number, the member ID, the plan's name, and the dates the notice was received and any appeal was sent.
Frequently asked questions
How long do I have to appeal a denied health insurance claim?
HealthCare.gov states that an internal appeal must be filed "within 180 days (6 months) of receiving notice that your claim was denied." The Department of Labor says employer plans must allow "at least 180 days." The plan's denial notice states its own deadline.
What is the difference between an internal appeal and an external review?
An internal appeal asks the plan to review its own decision. An external review sends the dispute to an independent reviewer, and HealthCare.gov states that the insurer "is required by law to accept the external reviewer's decision."
How long does an external review take?
HealthCare.gov states that standard external reviews are decided no later than 45 days after the request is received, and expedited reviews no later than 72 hours, or less depending on medical urgency.
Who can help if my plan is an employer plan?
The Department of Labor's Employee Benefits Security Administration handles questions about employer plan claims and lists its number as 1-866-444-3272. For insured plans, the state Department of Insurance is also a contact.
Sources, all read September 11, 2026: HealthCare.gov, "How to appeal an insurance company decision," "Internal appeals" and "External review," no dates shown. U.S. Department of Labor, Employee Benefits Security Administration, "Filing a Claim for Your Health Benefits," no date shown. National Association of Insurance Commissioners, "Health Insurance Claim Denied? How to Appeal the Denial," dated August 17, 2020.