Appeal
A formal request that your plan reconsider its denial of coverage.
An appeal is a formal request for your plan to reconsider a denial. Federal law (ERISA §503, ACA §2719) sets the minimum standards: 180 days to file, 30-60 days for plan decision (72 hours for urgent), required notice contents, the right to documents the plan relied on, and external review by an Independent Review Organization after internal exhaustion. Different plan types have different appeal tracks (5-level for Medicare Advantage, State Fair Hearing for Medicaid).
Frequently asked questions
What is appeal?
An appeal is a formal request for your plan to reconsider a denial. Federal law (ERISA §503, ACA §2719) sets the minimum standards: 180 days to file, 30-60 days for plan decision (72 hours for urgent), required notice contents, the right to documents the plan relied on, and external review by an Independent Review Organization after internal exhaustion. Different plan types have different appeal tracks (5-level for Medicare Advantage, State Fair Hearing for Medicaid).
Related terms
- Internal appealThe first formal review of a denial — conducted by the plan itself, by someone other than the origin
- External reviewBinding review by an Independent Review Organization after internal appeal is exhausted. The IRO dec
- Medical necessityThe standard for whether a service is required to diagnose or treat a condition — and the most commo
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