This article provides general educational information, not individual medical, legal or tax advice. Appeal eligibility, procedures and deadlines depend on your plan and the applicable review process. Confirm your instructions with the plan or review organization. Ask HealthQuoted about licensing and plan availability in your state.
In this guide
- A denial is a decision you can challenge
- Start with the denial notice and the records behind it
- File within 180 days—and make the evidence address the denial
- Know when the plan must answer
- If the denial stands, check eligibility for external review
- When waiting could harm your health, request expedited review
- Get help—and follow up on the outcome
A denial is a decision you can challenge
A letter saying treatment is “not medically necessary” can leave you wondering whose judgment counts: your clinician’s or your health plan’s. The denial does not necessarily end your claim. An internal appeal asks the plan to reconsider. An external review puts an eligible dispute before an independent reviewer.
This guide explains existing Affordable Care Act appeal protections for non-grandfathered individual and employer health plans. It is not a new policy announcement and does not cover Medicare or Medicaid appeals.
The specific ACA protections discussed here do not apply to grandfathered plans. That does not, by itself, tell you what other appeal options your coverage offers. Ask your plan about its status and procedures.
If you have employer coverage, ask whether it is self-funded or insured and which appeal process applies. Do not assume every employer plan follows the same route.
Start with the denial notice and the records behind it
For plans subject to these protections, the denial notice must explain the reason for the decision, your internal appeal rights, your right to request external review after an unsuccessful internal appeal, and the availability of a state Consumer Assistance Program where one exists.
Read the stated reason carefully. A medical-necessity dispute calls for a response to the plan’s medical reasoning; a dispute over whether a benefit is included raises a different question.
Ask the plan for relevant claim records and the medical-necessity criteria used in its decision. The official pages linked here do not explain which employer-plan records must be supplied free of charge.
- Save the denial letter and Explanation of Benefits, including any appeal instructions.
- Record when you received the notice so you can calculate your filing deadline.
- Keep notes of calls, including the date, time, person’s name and what was discussed.
- Keep copies of everything you submit, including signed representative forms.
HealthCare.gov: Documents to keep for an internal appeal ↗CMS: Information required in a denial notice ↗
File within 180 days—and make the evidence address the denial
HealthCare.gov says you must file an internal appeal within 180 days after receiving the denial notice. Follow your insurer’s form requirements or send a written appeal with your name, claim number and health insurance ID number. Include the additional information you want considered.
Ask your treating clinician for a letter that responds directly to the denial. Useful supporting material may explain your condition, why the requested care is appropriate and how relevant medical records support that explanation. These are practical suggestions, not a universal document checklist required by every plan.
Hypothetical example: A plan denies a requested treatment as not medically necessary. Rather than submitting only a statement that you disagree, you and your clinician identify the plan’s stated reason and provide a letter and relevant records explaining why the treatment is needed in your circumstances. That gives the appeal a clearer basis, but does not guarantee approval.
- State which denial you are appealing and what decision you want reconsidered.
- Organize supporting documents around the reason given in the denial.
- Confirm where and how to submit the appeal, and keep evidence of submission.
- If someone will appeal for you, complete the plan’s required authorization paperwork.
Know when the plan must answer
For a standard internal appeal, the decision deadline depends on whether you have already received the care. These are appeal deadlines—not the separate time limits for deciding the original claim.
Some group plans require more than one internal appeal level. CMS says all required internal levels must fit within the applicable overall timelines. At the end, the plan must provide a written decision. A final denial must explain how to request external review.
- Care not yet received: the internal appeal must be completed within 30 days.
- Care already received: the internal appeal process must be completed within 60 days.
- Urgent care: ask about expedited review rather than relying on standard timelines.
If the denial stands, check eligibility for external review
External review is not available for every disagreement. HealthCare.gov identifies eligible categories that include denials involving medical judgment, determinations that treatment is experimental or investigational, and certain coverage cancellations based on alleged false or incomplete application information. A medical-necessity denial involves the kind of medical judgment external review can address.
HealthCare.gov gives a four-month deadline for a written external-review request after you receive the applicable denial notice or final determination. Check the notice for the exact filing instructions and confirm your due date.
Depending on the plan and state, the process may be a state review program, the HHS-administered federal process or review through a contracted independent review organization. Your Explanation of Benefits or final internal denial should identify the organization handling the review. Confirm the route rather than assuming you should use the federal program.
Standard external reviews must be decided as soon as possible, with an outer limit of 45 days after receipt of the request.
HealthCare.gov: External review eligibility, routes and deadlines ↗
When waiting could harm your health, request expedited review
An expedited appeal may be available when the standard timetable would seriously jeopardize your life or your ability to regain maximum function. Explain the urgency and ask your clinician to provide supporting information.
In qualifying urgent circumstances, you may request external review before completing the internal process, including filing both requests at the same time.
CMS specifies a 72-hour deadline for urgent internal appeals. HealthCare.gov says expedited external reviews must be decided as quickly as the medical situation requires, no later than 72 hours after receipt. Its internal-appeals page also describes a four-business-day urgent-decision timeline. Because these summaries use different timing language, confirm the applicable expedited deadline with your plan or review organization and make the medical urgency clear.
CMS: Urgent internal appeals ↗HealthCare.gov: Urgent appeal requests ↗HealthCare.gov: Expedited external review ↗
Get help—and follow up on the outcome
Your state’s Consumer Assistance Program or Department of Insurance may be able to help with an appeal. You can also appoint a representative, such as a clinician familiar with your condition, to request external review for you. Complete the required authorization form.
The insurer must accept the external reviewer’s decision. If the reviewer overturns the denial, CMS says the insurer must provide the payment or services requested in the claim. Keep the decision and follow up with the plan about carrying it out.
HealthCare.gov: Representatives and help filing an appeal ↗CMS: What happens when an external reviewer overturns a denial ↗
Common questions
Does my doctor’s recommendation guarantee approval?
No. A clinician’s letter and supporting records can help explain why the denial should be reconsidered, but neither an internal appeal nor external review guarantees a favorable decision.
Does external review cost anything?
The HHS-administered federal external review process is free. HealthCare.gov says a state process or an issuer’s contracted independent review organization may charge a fee, but it cannot exceed $25 per external review.
Can I request appeal information in another language?
CMS says you may be entitled to appeal information in your native language upon request if you do not speak English. Ask your plan what language assistance is available.
Sources and publication details
- HealthCare.gov: Internal Appeals ↗
- HealthCare.gov: External Review ↗
- CMS: Appealing Health Plan Decisions ↗
Sources checked automatically Oct 12, 2026. AI-assisted article with automated editorial checks. Read our editorial process.