Internal appeal
The first level of appeal after a denial — review BY THE PLAN of its own decision. The mandatory first step before external review or court.
What it is
An internal appeal is a request that the health plan reconsider its denial of coverage. Federal law requires the review be conducted by someone OTHER than the original decision-maker (ERISA §503, 29 CFR §2560.503-1) and that the reviewer is qualified to make the clinical judgement involved (must consult an appropriately qualified health-care professional on questions involving medical judgement). Most plans have one or two internal levels.
Who can use it
Patients, parents/guardians, prescribers acting on behalf of patients, designated representatives, providers (with patient consent or authority).
When to use it
After ANY denial of coverage. Internal appeal is the mandatory first step before external review, state-fair-hearing, or court. Skipping internal appeal forfeits later remedies in most plan types.
Steps
- Read the denial notice carefully. The notice must state the specific reason, plan provision relied on, additional info needed (if any), and how to appeal. If anything is missing, request a corrected notice.
- Request the documents. ERISA §503 entitles you to all documents, records, and information relevant to the claim — including any internal rule or guideline relied on. Request them in writing.
- Gather clinical evidence. Chart notes, lab results, imaging reports, specialty-society guideline support, peer-reviewed literature. The appeal letter is only as strong as the evidence behind it.
- Draft the appeal letter. Cite the federal appeal-rights regulation, the insurer's own coverage policy, and the relevant clinical guideline. DenialHelp drafts this in about five minutes.
- Submit within the deadline. Federal floor is 180 days from the denial. Earlier is better — once submitted, the plan's clock starts.
- Track the plan's response. Plan has 30-60 days (72 hours for urgent). If they miss the deadline, escalate immediately — some plans auto-forward to external review.
Key deadlines
| Requirement | Deadline |
|---|---|
| Time to file internal appeal | 180 days from denial (ACA / ERISA floor) |
| Plan decision — pre-service | 30 days |
| Plan decision — post-service | 60 days |
| Plan decision — urgent care | 72 hours |
Frequently asked questions
What is internal appeal?
An internal appeal is a request that the health plan reconsider its denial of coverage. Federal law requires the review be conducted by someone OTHER than the original decision-maker (ERISA §503, 29 CFR §2560.503-1) and that the reviewer is qualified to make the clinical judgement involved (must consult an appropriately qualified health-care professional on questions involving medical judgement). Most plans have one or two internal levels.
Who can use internal appeal?
Patients, parents/guardians, prescribers acting on behalf of patients, designated representatives, providers (with patient consent or authority).
When should I use internal appeal?
After ANY denial of coverage. Internal appeal is the mandatory first step before external review, state-fair-hearing, or court. Skipping internal appeal forfeits later remedies in most plan types.
Time to file internal appeal — Internal appeal?
180 days from denial (ACA / ERISA floor)
Plan decision — pre-service — Internal appeal?
30 days
Plan decision — post-service — Internal appeal?
60 days
Plan decision — urgent care — Internal appeal?
72 hours
Related
- ERISA §503ERISA §503 is the foundational federal appeal-rights statute for the ~135 million Americans on emplo
- ACA §2719 (PHSA §2719)ACA §2719 guarantees every non-grandfathered group + individual health plan a standardised internal
- Expedited (urgent) appealWhen standard appeal timelines would jeopardise life, health, or function. Federal law mandates 72-h
- External review (IRO)Independent Review Organization (IRO) review — a binding decision by an outside organization after i
- Federal IDR (No Surprises Act dispute resolution)Federal Independent Dispute Resolution for OUT-OF-NETWORK provider payment disputes after the No Sur
- Grievance (vs appeal)A grievance is a complaint about plan conduct — service, access, quality — that does NOT involve a c
Sources
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