Billing & coverage
Appealing a private health plan denial
Internal appeals and independent external review for ACA-compliant plans, and why plan type changes the rules.
Key points
- For most ACA-compliant plans, an internal appeal must generally be filed within 180 days of the denial notice.
- Urgent-care claims qualify for expedited handling; internal and external review can sometimes run at the same time.
- After an internal denial, the patient can usually request external review by an independent reviewer — generally within 4 months of the final internal denial.
- Self-funded employer plans fall under federal ERISA rules administered by the Department of Labor; fully insured plans are also regulated by the state insurance department.
- Grandfathered plans may not have to follow all ACA appeal rules.
In practice
- Identify the plan type first: fully insured, self-funded (ERISA), Marketplace, Medicare Advantage or Medicaid managed care each route differently.
- Request the claim file, the plan document and the clinical criteria used — patients are generally entitled to them.
- Track every deadline from the date on the notice, not the date it arrived.
Official sources
- HealthCare.gov — Appealing a health plan decision (opens in a new tab)
- US Department of Labor — Employee Benefits Security Administration (opens in a new tab)
Educational summary, not legal advice. Deadlines depend on the notice, plan type and state.
Sources checked November 7, 2026. Rules change — confirm with the official source before acting.