Internal Appeal, Then External Review — A Real, Binding Two-Step Right
The Affordable Care Act guarantees most health plans provide two levels of review for a denied claim: an internal appeal with your insurer or plan, and, if that’s denied, an independent external review by a third party (45 CFR § 147.136). This applies to most non-grandfathered private plans — fully-insured and self-insured employer plans, and individual/marketplace plans. Grandfathered plans are largely exempt, but even they must allow external review for a narrow set of situations added by the No Surprises Act: out-of-network emergency services, certain non-emergency care by non-participating providers at participating facilities, and air ambulance services.
Deadlines here are easy to mix up because there are two different clocks. The original claim decision deadline is 15 days for a pre-service (not-yet-received) claim and 30 days for a post-service (already-received) claim. If that claim is denied and you appeal, the internal appeal decision deadline is different — 30 days for pre-service, 60 days for post-service — and both stages have a 72-hour deadline for urgent/expedited claims. Citing "30/60 days" as the original decision deadline, rather than the appeal decision deadline, is a common and understandable mix-up worth avoiding.
If your internal appeal is denied, you can request external review — either through your state’s external review process (many states have one) or, where a state process doesn’t apply, through the HHS-administered Federal External Review Process, currently run by a contractor via the externalappeal.cms.gov portal. You generally have 4 months from the final internal denial to request it; a standard external review decision is due within 45 days, and an expedited one within 72 hours. A decision overturning the denial is binding on the insurer.
What a Successful Appeal Gets You
The remedy is almost always the covered service itself — not damages for the denial
Overturned internal or external appeal
The insurer is required to cover the originally denied treatment or claim — the primary and most common real-world outcome.
ERISA litigation (if appeals are exhausted)
Recovery of the benefit owed and, at the court’s discretion, attorney’s fees — not extracontractual or punitive damages, per Massachusetts Mutual Life Ins. Co. v. Russell.
Medicare/Medicaid appeal levels
Reversal of the coverage decision at whichever appeal level succeeds — each with its own body deciding (contractor, independent contractor, ALJ, or court).
ERISA Plans: A Real Legal Limit You Should Know Before You Fight
Most employer-sponsored health plans are governed by ERISA, which layers its own claims-and-appeals rule (29 CFR § 2560.503-1) under the same ACA baseline described above — you generally must exhaust the internal appeal before suing under ERISA. The genuinely important, often-misunderstood limit: the Supreme Court held in Massachusetts Mutual Life Insurance Co. v. Russell (1985) that ERISA does not allow extracontractual or punitive damages for how a claim was handled — even a clearly wrongful or badly delayed denial. In practice, an ERISA lawsuit can generally recover the benefit itself and, at the court’s discretion, attorney’s fees — not damages for the harm the delay or denial caused you.
Whether your state’s Department of Insurance can help also depends on plan type: a fully-insured plan is subject to state insurance regulation, so your state DOI is a real resource. A self-funded (self-insured) employer plan is generally exempt from state insurance regulation under ERISA’s "deemer clause" — for those, the US Department of Labor’s Employee Benefits Security Administration (EBSA), not your state DOI, is the right federal contact. Many employees don’t know which type their plan is; your plan documents or HR department can confirm it, and it changes who can actually intervene.
How to Appeal, Step by Step
Identify your plan type and situation first — it determines which process and deadlines actually apply
Confirm your plan type: fully insured, self-funded, Medicare, or Medicaid
Check your plan documents or ask HR. This determines whether your state Department of Insurance, the federal DOL/EBSA, or a Medicare/Medicaid-specific process is the right escalation path.
File the internal appeal before the deadline, and request expedited review if urgent
For urgent situations, ask specifically for expedited/urgent handling (usually needs physician certification) to get the 72-hour track instead of the standard 30/60-day timeline.
If denied, request external review within 4 months
Through your state’s external review process or the HHS Federal External Review Process at externalappeal.cms.gov — this is an independent, binding decision, not just another internal review.
For an ERISA self-funded plan, know the real limits before litigating
Exhaust internal appeals first; understand that a lawsuit will generally recover the benefit itself and possibly fees, not damages for the denial’s impact on you.
For Medicare, follow the five-level appeal path in order
Redetermination (within 120 days of the initial determination) → reconsideration by a Qualified Independent Contractor (within 180 days of redetermination) → ALJ hearing → Medicare Appeals Council → federal court, with dollar-amount thresholds at the later levels. verify current dollar thresholds, which adjust annually
For an ER refusal of care, this is an EMTALA issue, not a claims appeal
If a hospital emergency department refused to screen or stabilize you regardless of insurance or ability to pay, that’s a potential EMTALA violation — complaints go to your state health department or CMS, not through the claims-appeal process.
Documents to gather
- The denial letter/Explanation of Benefits (EOB), with the specific reason given
- Your plan documents or Summary of Benefits and Coverage
- Medical records and physician letters supporting medical necessity
- Dates of every step: claim submission, denial, internal appeal filing, and internal appeal decision
Timelines and Limitation Periods
Two different clocks at the internal-appeal stage, plus separate Medicare and Medicaid timelines
Don’t confuse the original claim decision deadline with the internal appeal decision deadline — they’re different, and both matter.
| Jurisdiction | Limitation Period |
|---|---|
| US — original claim decision (urgent / pre-service / post-service) | 72 hours / 15 days / 30 days |
| US — internal appeal decision (urgent / pre-service / post-service) | 72 hours / 30 days / 60 days |
| US — request external review after final internal denial | 4 months |
| US — external review decision (standard / expedited) | 45 days / 72 hours |
| US — Medicare redetermination request | 120 days from the initial determination |
| US — Medicare reconsideration request (QIC) | 180 days from the redetermination decision |
| US — Medicaid fair hearing request | Reasonable time, not more than 90 days, per federal minimum (42 CFR Part 431 Subpart E) — varies further by state |
Realistic Outcomes and Caveats
A well-documented internal or external appeal, filed on time and citing medical necessity, is the process most likely to get you the actual care or claim covered — this is the main real lever, and it’s a binding, independent process at the external-review stage, not just a formality.
If you end up in ERISA litigation, be realistic: the Supreme Court’s ruling in Massachusetts Mutual Life Ins. Co. v. Russell means you should not expect damages for the harm caused by the delay or denial itself, even in an egregious case — the remedy is generally the benefit itself plus possible attorney’s fees.
This page can help you route your situation to the right process and deadline, but it cannot predict whether a specific insurer, Medicare contractor, or state agency will rule in your favor.
Common Pitfalls
Missing the 4-month external review deadline
This runs from your final internal denial — missing it can forfeit your right to an independent, binding review of the decision.
Not requesting expedited/urgent handling when it applies
Without an affirmative request (usually needing physician certification), your appeal defaults to the standard, slower timeline even if your situation is genuinely urgent.
Expecting ERISA litigation to compensate you for the denial’s impact
Extracontractual and punitive damages are generally unavailable under ERISA per Massachusetts Mutual Life Ins. Co. v. Russell — a frequently misunderstood limit worth knowing before you litigate.
Contacting your state Department of Insurance about a self-funded plan
Self-funded employer plans are largely exempt from state insurance regulation — the federal DOL/EBSA, not your state DOI, is generally the right contact for those.
Treating an ER refusal of care as a claims-appeal issue
A hospital ER refusing to screen or stabilize you is an EMTALA matter, reported to your state health department or CMS — a different process from appealing a coverage denial.
Organize Your Healthcare Access Denial Case
Use the calculator to document the denial, your plan type, and the timeline before filing an internal appeal or external review request.
Organize Your Healthcare Access Denial Case
Use the calculator to document the denial, your plan type, and the timeline before filing an internal appeal or external review request.
This stays in your private workspace until you choose a next step. It does not submit a claim on your behalf on its own.
Official and Legal References
- eCFR — 45 CFR § 147.136 (internal claims and appeals, external review)
- Cornell LII — 29 CFR § 2560.503-1 (ERISA claims procedure)
- Healthcare.gov — External Review
- CMS — HHS-Administered Federal External Review Process
- Medicare.gov — Appeals in Original Medicare
- CMS — Emergency Room Rights (EMTALA) and How to File a Complaint
- Justia — Massachusetts Mutual Life Ins. Co. v. Russell, 473 U.S. 134 (1985)
- eCFR — 42 CFR Part 431, Subpart E (Medicaid fair hearings)
Fully Insured vs. Self-Funded vs. Medicare vs. Medicaid
A fully-insured employer plan or an individual/marketplace plan is subject to state insurance regulation, so your state Department of Insurance can help. A self-funded employer plan is largely exempt from state insurance rules under ERISA’s "deemer clause" — the federal DOL/EBSA is the relevant contact instead, and any lawsuit is subject to ERISA’s no-extracontractual-damages limit. Medicare and Medicaid each run their own separate, multi-level federal appeal structures, distinct from the ACA/ERISA internal-external review process described above.
Frequently Asked Questions
Real edge cases, answered in plain language
My insurer took over 30 days to decide my appeal — is that allowed?
Can I sue my employer’s health plan for damages because of a wrongful denial?
An ER turned me away because I don’t have insurance — is that legal?
Organize Your Healthcare Access Denial Case
Use the calculator to document the denial, your plan type, and the timeline before filing an internal appeal or external review request.