{"service":"Health Appeal","site":"https://healthappeal.ai","rules_last_reviewed":"2026-09-21","note":"Deadlines are counted from the date printed on the notice. The date printed on a person's own notice always controls. This is general information, not legal advice.","plan_types":{"medicare_advantage":{"label":"Medicare Advantage (Part C)","clues":"The card names a private insurer (UnitedHealthcare, Humana, Aetna, a Blue plan and so on) and says Medicare Advantage, HMO, PPO or Part C. The person is 65 or older, or on Medicare through disability.","first":{"name":"Reconsideration by the plan","days":65,"counted_from":"the date on the denial notice (called an organization determination, often titled Notice of Denial of Medical Coverage or Payment)","file_with":"The Medicare Advantage plan, at the appeals address or fax number on the denial notice. The patient, their representative, or their doctor can file.","how":"In writing. Urgent requests can be made by phone. If a doctor asks for a fast appeal, the plan must treat it as fast.","they_must_answer":"Within 30 days for care not yet received, 60 days for a payment dispute, 7 days for a Part B drug, and 72 hours for a fast (expedited) appeal."},"next":{"name":"Independent Review Entity, then an Administrative Law Judge","you_must_file":false,"text":"If the plan says no again, in whole or in part, it must send the case automatically to Medicare's Independent Review Entity. The patient does not have to file anything for that step, but can send the reviewer extra evidence. If the independent reviewer also says no, the decision letter explains how to ask for a hearing with an Administrative Law Judge, usually within 60 days, if the amount in dispute meets a minimum that changes each year."},"late":"A late appeal can still be accepted for good cause, such as serious illness or a notice that never arrived. Ask in writing and explain why.","sources":["42 CFR 422.582 (65 day filing window)","42 CFR 422.590 (plan decision deadlines and automatic forwarding)","cms.gov: Reconsideration by the Medicare Advantage (Part C) Health Plan","medicare.gov: Appeals in Medicare health plans"]},"medicare_part_d":{"label":"Medicare prescription drug plan (Part D)","clues":"A pharmacy or drug plan refused to cover a prescription, or wants step therapy or prior authorization first. The plan is a stand-alone drug plan or the drug part of a Medicare Advantage plan.","first":{"name":"Redetermination by the drug plan","days":65,"counted_from":"the date on the plan's written coverage determination","file_with":"The Part D plan, at the address, fax or phone number on the denial notice. The prescriber can file on the patient's behalf.","how":"In writing or by phone. A supporting statement from the prescriber is the most important attachment, especially for an exception to the formulary or to step therapy.","they_must_answer":"Within 7 days for a standard request about a drug not yet received, 14 days for a repayment request, and 72 hours for a fast (expedited) request."},"next":{"name":"Reconsideration by the Independent Review Entity","you_must_file":true,"days":65,"text":"Unlike Medicare Advantage medical appeals, a Part D case is not forwarded automatically. The patient, representative or prescriber has to ask the Independent Review Entity for a reconsideration, using the instructions in the plan's redetermination notice."},"late":"A late request can be accepted for good cause. Ask in writing and explain why.","sources":["42 CFR 423.582 (filing window)","42 CFR 423.590 (plan decision deadlines)","medicare.gov: Appeals in a Medicare drug plan"]},"original_medicare":{"label":"Original Medicare (Parts A and B)","clues":"The red, white and blue Medicare card is the only medical card. Denials arrive on a Medicare Summary Notice (MSN) mailed every three months.","first":{"name":"Redetermination by the Medicare contractor","days":120,"counted_from":"the date on the Medicare Summary Notice (the law counts from receipt, presumed five days after that date, so this is the safer date)","file_with":"The Medicare Administrative Contractor named in the Appeals Information section of the Medicare Summary Notice.","how":"Circle the denied item on the MSN, write why you disagree, sign it and mail it to the address on the MSN, or use form CMS-20027. Attach a letter from the doctor if you can.","they_must_answer":"Generally within 60 days."},"next":{"name":"Reconsideration by a Qualified Independent Contractor","you_must_file":true,"days":180,"text":"If the redetermination is unfavorable, the patient can ask a Qualified Independent Contractor for a reconsideration within 180 days of receiving that decision, using form CMS-20033 or the instructions in the decision letter. After that comes a hearing before an Administrative Law Judge, usually within 60 days, if the amount in dispute meets the yearly minimum."},"late":"A late request can be accepted for good cause. Ask in writing and explain why.","sources":["42 CFR 405.942 (120 day window)","42 CFR 405.962 (180 day window for reconsideration)","medicare.gov: Appeals in Original Medicare"]},"employer_plan":{"label":"Health plan from a private employer or union","clues":"Coverage comes through a job at a private company or a union, for the worker or a family member. Most of these plans are governed by the federal law called ERISA. The denial is usually an Explanation of Benefits or an adverse benefit determination letter.","first":{"name":"Internal appeal to the plan","days":180,"counted_from":"the date on the denial (the law gives at least 180 days from receipt; a plan may give more, never less)","file_with":"The plan or its claims administrator, at the appeals address in the denial letter. Some employer plans have two internal levels; the letter says so.","how":"In writing. Urgent appeals can be made by phone. People in this situation often ask for a free copy of the claim file and the criteria used, which 29 CFR 2560.503-1(h)(2)(iii) requires plans to provide on request.","they_must_answer":"Within 72 hours for urgent care, 30 days for care not yet received, and 60 days for care already received. If the plan has two levels, each level gets half that time."},"next":{"name":"External review by an independent organization","you_must_file":true,"months":4,"text":"After the final internal denial, most plans (all that are not grandfathered) must offer external review by an Independent Review Organization for denials that involve medical judgment, such as medical necessity or experimental treatment. The request is due within four months of the final internal denial. The reviewer's decision binds the plan, and the review is free or nearly free. The final denial letter says where to send the request. The letter must also describe the right to bring a civil action under ERISA section 502(a); only a licensed attorney can advise on that, and plan documents can set short time limits."},"late":"Employer plans do not have to accept late appeals. If the deadline has passed, appeal anyway, explain the delay, and ask the plan to consider it.","sources":["29 CFR 2560.503-1(h)(3)(i) (at least 180 days to appeal)","29 CFR 2560.503-1(i) (plan decision deadlines)","29 CFR 2590.715-2719 (external review, four months)","dol.gov/agencies/ebsa: Filing a Claim for Your Health Benefits"]},"marketplace_or_individual":{"label":"Plan bought on HealthCare.gov, a state marketplace, or directly from an insurer","clues":"The person or family bought the plan themselves, through HealthCare.gov, a state exchange, a broker, or the insurer's website. Not through a job and not Medicare or Medicaid.","first":{"name":"Internal appeal to the insurer","days":180,"counted_from":"the date on the denial notice (the rule counts 180 days from receiving it)","file_with":"The insurance company, at the appeals address in the denial letter or Explanation of Benefits.","how":"In writing, using the insurer's appeal form or a letter with the patient's name, claim number and member ID. Urgent appeals can be made by phone, and an urgent external review can be requested at the same time.","they_must_answer":"Within 72 hours for urgent care, 30 days for care not yet received, and 60 days for care already received."},"next":{"name":"External review by an independent organization","you_must_file":true,"months":4,"text":"After the final internal denial, the patient can ask for an external review within four months. An independent reviewer decides, and the insurer has to follow the decision. A standard review is decided within 45 days and an urgent one within 72 hours. The final denial letter names who runs the review in that state. Where the federal process applies, requests go through externalappeal.cms.gov or 1-888-866-6205. Some states run their own process with different windows, so the date in the final denial letter controls."},"late":"Insurers do not have to accept late internal appeals. If the deadline has passed, appeal anyway, explain the delay, and also contact the state insurance department.","sources":["45 CFR 147.136 (internal appeals and external review)","healthcare.gov: Internal appeals","healthcare.gov: External review"]},"medicaid_managed_care":{"label":"Medicaid through a health plan (managed care)","clues":"The person has Medicaid, and the card names a health plan or managed care company (for example Molina, Centene, a Blue plan, UnitedHealthcare Community Plan). The denial is called a Notice of Adverse Benefit Determination.","first":{"name":"Appeal to the Medicaid health plan","days":60,"counted_from":"the date on the Notice of Adverse Benefit Determination","file_with":"The Medicaid health plan, using the phone number or address on the notice.","how":"By phone or in writing. The plan must give the case file free of charge on request.","they_must_answer":"Within 30 days for a standard appeal and 72 hours for a fast (expedited) appeal."},"next":{"name":"State fair hearing","you_must_file":true,"days":90,"text":"If the plan upholds its decision, the patient can ask the state for a fair hearing. Federal rules let each state set that window anywhere from 90 to 120 days from the date on the plan's appeal decision, so 90 days is the safe number unless the notice gives a later date. If the plan misses its own deadline, the patient can go straight to a fair hearing."},"keep_services":"If the plan is reducing or stopping a service the person already gets, they can usually keep the service during the appeal by asking within 10 days of the date on the notice, or before the change takes effect, whichever is later. If the appeal is lost, the state may be allowed to bill for that care.","late":"Ask the plan in writing to accept the late appeal and explain why, and call the state Medicaid agency.","sources":["42 CFR 438.402(c)(2)(ii) (60 days to appeal)","42 CFR 438.408 (plan decision deadlines; 90 to 120 days for a fair hearing)","42 CFR 438.420 (keeping services during an appeal)"]},"medicaid_state":{"label":"Medicaid directly from the state (no health plan)","clues":"The person has Medicaid and the denial came from the state Medicaid agency or county office itself, not from a named health plan.","first":{"name":"State fair hearing","days":null,"counted_from":"the date on the notice","file_with":"The state Medicaid agency or hearing office named on the notice.","how":"Follow the hearing request instructions on the notice. Most states accept a phone call, a form or a letter.","they_must_answer":"States generally must decide within 90 days of the hearing request."},"next":{"name":"Further review under state law","you_must_file":true,"text":"The hearing decision explains any further review available under that state's law."},"keep_services":"If a current service is being cut or stopped, asking for the hearing before the effective date of the change (often within 10 days of the notice) usually keeps the service in place until the hearing decision.","late":"Call the state Medicaid agency and legal aid right away.","no_date_reason":"Each state sets its own window for fair hearing requests, up to a federal maximum of 90 days, and some states allow only 30. The deadline printed on the notice is the one that counts.","sources":["42 CFR 431.221(d) (state sets the window, 90 day maximum)","42 CFR 431.230 (keeping services until the hearing decision)"]},"federal_employee_fehb":{"label":"Federal employee or retiree plan (FEHB or PSHB)","clues":"Coverage comes from federal government employment or retirement, or the Postal Service, through the Federal Employees Health Benefits or Postal Service Health Benefits program.","first":{"name":"Reconsideration by the plan","months":6,"counted_from":"the date of the plan's initial decision","file_with":"The health plan, at the address in Section 8 of the plan brochure or in the denial letter.","how":"In writing. Explain why the claim should be paid based on the specific benefit provisions in the plan brochure, and attach supporting records.","they_must_answer":"Within 30 days of receiving the request (72 hours for urgent care). The plan can ask for more information, which adds time."},"next":{"name":"Review by the Office of Personnel Management (OPM)","you_must_file":true,"days":90,"text":"If the plan upholds its denial, the enrollee can ask OPM to review within 90 days of the date on the plan's letter. If the plan does not answer within 30 days, OPM review can be requested within 120 days of the original reconsideration request. OPM generally decides within 60 days. The address is in Section 8 of the plan brochure."},"late":"Deadlines can be extended if the enrollee shows they were prevented from filing by circumstances beyond their control.","sources":["5 CFR 890.105 (FEHB disputed claims process)","Section 8 of each plan's FEHB brochure"]},"tricare":{"label":"TRICARE (military)","clues":"Coverage comes from active duty, Guard or Reserve service, military retirement, or a family member's service.","first":{"name":"Appeal to the TRICARE regional contractor","days":90,"counted_from":"the date on the Explanation of Benefits or denial decision","file_with":"The TRICARE contractor, at the appeals address on the Explanation of Benefits or decision.","how":"In a signed letter that is postmarked or received within 90 days. Include a copy of the decision and supporting documents. If documents are missing, send the appeal on time and say more is coming. A fast appeal of a prior authorization or inpatient denial must be filed within three calendar days.","they_must_answer":"Generally within 60 days for a standard reconsideration."},"next":{"name":"Second reconsideration, then an independent hearing","you_must_file":true,"days":90,"text":"For medical necessity denials, the next level is the TRICARE Quality Monitoring Contractor, within 90 days of the date on the appeal decision. If the disputed amount is 300 dollars or more, an independent hearing can be requested from the Defense Health Agency after that."},"late":"Send the appeal anyway and explain the delay.","sources":["32 CFR 199.10 (TRICARE appeal procedures)","tricare.mil: Medical Necessity Appeals"]},"government_or_church_employer":{"label":"Plan from a state, city, school district or church employer","clues":"Coverage comes through a job with a state or local government, a public school or university, or a church or religious organization. These plans are not governed by ERISA.","first":{"name":"Internal appeal to the plan","days":180,"counted_from":"the date on the denial notice","file_with":"The plan or its claims administrator, at the appeals address in the denial letter.","how":"In writing, following the instructions in the denial letter and the plan booklet.","they_must_answer":"Usually within 72 hours for urgent care, 30 days for care not yet received, and 60 days for care already received."},"next":{"name":"External review, where it applies","you_must_file":true,"months":4,"text":"Most non-grandfathered government plans follow the same federal appeal rules as private insurance, including external review within four months of the final denial. Church plans and some self-funded government plans can differ. The final denial letter and the plan booklet control."},"confirm":"This number is the usual federal standard, but these plans vary. Confirm the deadline in the denial letter or plan booklet before relying on it.","late":"Appeal anyway, explain the delay, and check the plan booklet for its own rules.","sources":["45 CFR 147.136 (applies to most non-grandfathered non-federal government plans)","The plan's own booklet or summary plan description"]},"short_term_or_other":{"label":"Short-term plan, fixed indemnity plan, or health care sharing ministry","clues":"The plan was sold as short-term, limited duration, supplemental, fixed indemnity, or as a faith-based sharing program. These are not comprehensive health insurance and most federal appeal protections do not apply.","first":{"name":"Whatever the policy or membership guidelines provide","days":null,"counted_from":"the date on the denial","file_with":"The company, following the appeal or dispute section of the policy or the sharing guidelines.","how":"In writing. Ask for the specific policy language relied on.","they_must_answer":"Set by the policy and by state law."},"next":{"name":"State insurance department","you_must_file":true,"text":"For an insurance policy, a complaint to the state insurance department is the main outside remedy. Health care sharing ministries are generally not insurance, so the insurance department may have limited power, and the state attorney general's consumer protection office is the alternative."},"late":"Check the policy for its own deadline and contact the state insurance department.","no_date_reason":"These products set their own appeal windows in the policy or membership guidelines. Read that section now, because some windows are short.","sources":["The policy or membership guidelines","State insurance law"]}},"care_ending_fast_appeals":{"care_ending_notice":{"applies_to":["medicare_advantage","original_medicare"],"name":"Fast appeal to the Quality Improvement Organization (BFCC-QIO)","rule":"Ask for the fast appeal no later than noon of the day before the termination date listed on the Notice of Medicare Non-Coverage.","file_with":"The BFCC-QIO named on the notice, by phone. The number is printed on the notice. This is an independent reviewer, not the plan.","they_must_answer":"Usually by the end of the day after the reviewer has the information it needs. Care continues to be covered while the reviewer decides.","also":["This covers care ending in a skilled nursing facility, home health, hospice, or outpatient rehabilitation (CORF).","Ask the provider for the Detailed Explanation of Non-Coverage. They must give it by the end of the day the reviewer notifies them.","The reviewer will ask for the patient's view. Be ready to say, in plain words, what skilled care the patient still needs each day and what happens without it.","Medicare coverage of skilled nursing and therapy does not depend on whether the patient is improving. Skilled care needed to maintain a condition or slow decline can qualify (Jimmo v. Sebelius settlement).","If the noon deadline is missed, a review can still be requested, but the patient may be billed for care after the termination date. Call anyway.","If the fast appeal is lost, a second fast review can be requested by noon of the day after the decision."],"sources":["42 CFR 422.624 and 422.626 (Medicare Advantage)","42 CFR 405.1200 and 405.1202 (Original Medicare)","medicare.gov: Fast appeals"]},"hospital_discharge":{"applies_to":["medicare_advantage","original_medicare"],"name":"Fast appeal of a hospital discharge to the Quality Improvement Organization (BFCC-QIO)","rule":"Ask for the fast appeal no later than the planned day of discharge, and before leaving the hospital.","file_with":"The BFCC-QIO named on the notice called An Important Message from Medicare, by phone.","they_must_answer":"Usually within one day of getting the information it needs. The patient can stay without paying for the extra days (other than normal cost sharing) while the reviewer decides.","also":["If the hospital did not give the Important Message from Medicare notice, ask for it.","If the deadline is missed, a review can still be requested, but the patient may have to pay for days after the planned discharge date."],"sources":["42 CFR 422.620 and 422.622 (Medicare Advantage)","42 CFR 405.1205 and 405.1206 (Original Medicare)","medicare.gov: Fast appeals"]}},"denial_reasons":{"medical_necessity":{"label":"Not medically necessary","looks_like":"The letter says the service is not medically necessary, does not meet criteria or guidelines, or that a lower level of care would do.","points":["Quote the exact reason and criteria the insurer gave, then answer each one with a fact from the medical record.","State what the treating doctor ordered, why, and what happens to the patient without it.","Name the recognized clinical guideline or specialty society recommendation the doctor relied on, if there is one. The doctor's office can supply it.","Point out anything the reviewer missed: other conditions, failed earlier treatments, complications, living situation, fall risk.","Ask whether the reviewer was a doctor in the same specialty, and ask for their name and credentials."],"evidence":["Letter of medical necessity from the treating doctor","Relevant office notes, test results and imaging reports","Records of treatments already tried and why they failed","The guideline or criteria the insurer cited, which the appeal rules let people request"]},"care_ending_too_soon":{"label":"Care is being cut short (skilled nursing, rehab, home health, hospital)","looks_like":"The plan approved some days or visits and now says further days are not covered, or has given a discharge or non-coverage notice.","points":["If a Notice of Medicare Non-Coverage or a hospital discharge notice was given, the fast appeal by phone comes first. A letter comes second.","Describe what skilled care the patient receives each day and why it takes a nurse or therapist to provide it safely.","Describe function now compared with before the illness: walking, transfers, bathing, swallowing, memory, wounds, medications.","For Medicare, improvement is not required. Skilled care that maintains function or slows decline can be covered (Jimmo v. Sebelius).","Explain why discharge now is unsafe: who is at home, stairs, fall history, what the therapists have documented.","Ask whether a software tool or predicted length of stay was used, and for the clinician who reviewed this patient's own circumstances."],"evidence":["Statement from the treating doctor or facility physician that skilled care is still needed","Recent therapy notes and nursing notes","The non-coverage or discharge notice itself","Any written prediction or target discharge date given by the plan"]},"experimental_investigational":{"label":"Experimental or investigational","looks_like":"The letter calls the treatment experimental, investigational, unproven, or not the standard of care.","points":["Show the treatment is accepted practice: FDA approval or clearance, listing in recognized compendia, specialty society guidelines, peer-reviewed studies.","Explain why standard alternatives were tried and failed, or are unsafe for this patient.","Ask for the insurer's medical policy that labels the treatment experimental and the date it was last updated.","This kind of denial is one that independent external reviewers are specifically set up to decide."],"evidence":["Doctor's letter with citations to guidelines and studies","FDA approval or compendia listing if it is a drug or device","Records showing alternatives tried"]},"out_of_network":{"label":"Out of network","looks_like":"The letter says the provider or facility is out of network, or pays far less than billed for that reason.","points":["If it was an emergency, say so plainly. Emergency care must be covered at in-network cost sharing under the federal No Surprises Act, regardless of network.","If an out-of-network clinician treated the patient at an in-network hospital or surgery center without a signed consent, the No Surprises Act generally protects the patient from the extra bill.","If no in-network provider could deliver the care within a reasonable time or distance, state who was called, when, and what they said, and ask for a network gap exception.","If the plan's own directory listed the provider as in network, attach a screenshot or printout."],"evidence":["Emergency room record or ambulance record if applicable","Notes of calls to in-network providers with dates and names","Directory screenshot","Referring doctor's letter on why this provider was needed"]},"no_prior_authorization":{"label":"No prior authorization or referral","looks_like":"The letter says approval was required before the service and was not obtained, or that there was no referral.","points":["If it was an emergency, say so. Federal rules (the Affordable Care Act and the No Surprises Act) bar plans from requiring prior authorization for emergency care.","If the provider was responsible for getting the authorization, say so and ask the provider's billing office to file a corrected or retroactive request as well.","If an authorization was given, attach the authorization number, date, and the name of the person spoken to.","Ask the plan to review medical necessity now, after the fact, and attach the doctor's letter."],"evidence":["Authorization or reference number if one exists","Phone log with dates and names","Doctor's letter of medical necessity","Emergency records if applicable"]},"not_covered_benefit":{"label":"Not a covered benefit, or excluded","looks_like":"The letter says the plan does not cover this service at all, or cites an exclusion.","points":["Ask for the exact plan language relied on, with the page and section, and read it against the service actually provided. Exclusions are often applied too broadly.","If the service is an essential health benefit, preventive care, or mental health or substance use care, say so. Federal law limits how plans can exclude or restrict these.","If the wrong code made a covered service look like an excluded one, ask the provider to correct and resubmit the claim.","For Medicare Advantage, the plan must cover what Original Medicare covers."],"evidence":["The plan booklet section the insurer cited","The itemized bill with procedure and diagnosis codes","Doctor's letter describing what was done and why"]},"coding_or_billing_error":{"label":"Coding, billing or paperwork problem","looks_like":"The letter mentions missing information, a duplicate claim, a wrong code, timely filing, or coordination of benefits.","points":["Call the provider's billing office first. Most of these are fixed by a corrected claim, which is faster than an appeal.","File the appeal anyway to protect the deadline, and say a corrected claim is being submitted.","If the denial is for the provider filing late, an in-network provider usually cannot bill the patient for that. Say so, and ask the plan to confirm it in writing.","If the issue is which insurance pays first, give both insurers the other's details in writing."],"evidence":["Itemized bill","The Explanation of Benefits","Notes of the call with the billing office","Other insurance information if there are two plans"]},"step_therapy_or_formulary":{"label":"Drug not on the list, or must try another drug first","looks_like":"The letter says the drug is non-formulary, needs step therapy or prior authorization, or exceeds a quantity limit.","points":["Ask for a formulary or step therapy exception. The prescriber's supporting statement is what decides these.","The statement should say which listed drugs were already tried, for how long, and what happened, or why they would be unsafe or less effective for this patient.","If the patient is stable on the drug, say so, and describe the risk of switching.","If waiting would seriously harm the patient, ask for a fast (expedited) decision."],"evidence":["Prescriber's supporting statement","Pharmacy records showing drugs already tried","Relevant lab results or notes"]},"other":{"label":"Something else, or the letter is unclear","looks_like":"The reason does not fit the other categories, or the letter gives no clear reason.","points":["A denial has to state the specific reason and the plan provision or criteria relied on. If it does not, say so and ask for them in writing.","Ask for the complete claim file.","State clearly what decision you want."],"evidence":["The denial letter","Doctor's letter","Relevant records"]}}}