Coverage type · Job-based plan
Employer plan bought from an insurer (fully insured)
Your employer buys a policy and the insurance company pays your claims. You have federal appeal rights and your state insurance department and state external review process, so you have more places to turn than with a self-funded plan.
On this page 7
- Who has this
- People who get health coverage through an employer or union that buys an insurance policy, so the insurance company, not the employer, bears the cost of claims.
- Who regulates it
- Your state insurance department regulates the insurance company and its policy. The Department of Labor's Employee Benefits Security Administration (EBSA, help line 1-866-444-3272) also oversees private employer plans.
- Can your state help?
- Yes. A fully insured employer plan is covered by both the Employee Retirement Income Security Act (ERISA) and the state insurance law that binds the insurer. Your state insurance department can take a complaint, and the state external review process applies where your state's process meets the federal standards. Find your state.
How to tell this is your coverage
- Read your summary plan description (SPD, the booklet that explains your plan). Where an insurer is involved, it must say whether and to what extent benefits are guaranteed under an insurance contract, and what the insurer does. If it says benefits are provided under a policy issued by the insurer, the plan is fully insured.
- Ask your human resources department or plan administrator: Is our plan fully insured or self-funded? Is the company on my card the insurer that carries the cost, or only the claims administrator?
- Ask for the plan documents in writing. The plan administrator must send the latest summary plan description on written request, and may charge no more than 25 cents a page.
- Search the Department of Labor's public Form 5500 database for your employer's health plan. Treat it as a clue only: a plan with fewer than 100 participants that is insured, unfunded, or both may not have to file, so finding nothing proves nothing.
The appeal steps, in order
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First appeal to the insurer
Official name: Internal appeal (an appeal of an adverse benefit determination)
- Who decides
- The insurer. The reviewer must be someone who did not make the first decision and does not report to that person, and must not defer to it. If the denial rests on a medical judgment, the reviewer must consult a health professional who was not involved in the first decision.
- Your deadline
- At least 180 days after you receive the denial notice. Your plan may allow more time, never less. Check the date on your notice, which controls.
- Their deadline
- Urgent care: as soon as possible and no later than 72 hours after your appeal is received. Care you need approved first: 30 days (15 days at each level if your plan has two levels). Care you already received: 60 days (30 days at each level if two levels). Check the date on your notice, which controls.
- What to send
- A written appeal naming the claim and the denial, with your records, your doctor's letter and your reasons. Ask first for your claim file, which the plan must give you free. If the plan is not grandfathered, it must also give you any new evidence or reasons it uses, free and early enough for you to answer, before it issues a final internal denial. There is no fee to appeal.
- If you lose, or hear nothing
- If the insurer upholds the denial and has a second appeal level, file it. Otherwise request independent external review.
- The rule
- 29 CFR 2590.715-2719(b), internal claims and appeals for group plans
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Second appeal to the insurer (only if your plan has one)
Official name: Second-level internal appeal
- Who decides
- The insurer. A group health plan may not require more than two appeals before you can sue.
- Your deadline
- Set by your plan documents and stated in the first appeal decision. It is not a fresh 180 days. Check the date on your notice, which controls.
- Their deadline
- Half the usual time at each level: 15 days before care and 30 days after care for each level if your plan has two levels. If urgent, no later than 72 hours. Check the date on your notice, which controls.
- What to send
- A new letter answering the reasons in the first appeal decision, with any new records or doctor's statement.
- If you lose, or hear nothing
- If the insurer upholds the denial again, request external review. The window for external review starts from the final internal denial.
- The rule
- 29 CFR 2560.503-1(c) and (i)(2), number of appeal levels and decision times
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Independent external review through your state
Official name: State external review by an independent review organization (IRO)
- Who decides
- An independent review organization (IRO) assigned by the state or another independent body, never chosen by the insurer, the plan or you. It looks at the claim fresh. In Alabama, Florida, Georgia, Texas and Wisconsin, as listed by the Centers for Medicare & Medicaid Services (CMS) on 11 November 2026, insurers use a private accredited IRO or the federal government's process instead, because those states have no process that meets the federal standards.
- Your deadline
- At least 4 months after you receive the denial notice (the final internal denial, if you appealed first). Your state may allow longer. Check the date on your notice, which controls.
- Their deadline
- A standard decision is due within 45 days after the IRO receives your request. An urgent decision is due as fast as your medical situation requires and no later than 72 hours.
- What to send
- Follow the instructions in your final denial notice or your state's process. Include the denial notice, your records and your doctor's letter. You can send the IRO more information for at least 5 business days after its notice under a state process. Denials involving medical judgment, No Surprises Act protections or a cancellation of coverage (rescission) qualify; so can an out-of-network or visit-limit denial that turns on medical judgment. A state may keep a filing fee only if state law allowed it as of 18 November 2015: it may not exceed $25, must be refunded if you win, must be waived for hardship, and may not exceed $75 per person per plan year.
- Form
- Which states use which external review process (Centers for Medicare & Medicaid Services)
- If you lose, or hear nothing
- If the IRO overturns the denial, the insurer must provide coverage or payment immediately, even if it plans to go to court. If it upholds the denial, complain to the state, call a Consumer Assistance Program, and talk to a lawyer about a lawsuit.
- The rule
- 29 CFR 2590.715-2719(c), state external review standards
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Complaint to the state insurance department
Official name: Regulator complaint
- Who decides
- Your state insurance department, which regulates the insurer. HealthCare.gov also points people to their state Consumer Assistance Program, which can file an appeal for you. The federal Employee Benefits Security Administration can take complaints about the employer's plan.
- Your deadline
- We could not confirm a federal deadline for this step. A complaint does not stop your appeal or external review deadlines, so keep them running. Check the date on your notice, which controls.
- Their deadline
- Set by your state. We did not confirm a federal response time.
- What to send
- A short written complaint with your policy or member number, the denial notice, the dates of every appeal, and what you ask the department to look into.
- Form
- Find your state insurance department (National Association of Insurance Commissioners)
- If you lose, or hear nothing
- Use what the department tells you in your external review request or a lawsuit.
- The rule
- HealthCare.gov, internal appeals
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Lawsuit in court
Official name: Civil action under section 502(a) of the Employee Retirement Income Security Act (ERISA)
- Who decides
- A federal or state judge. The court reviews the denial fresh unless the plan gives its administrator discretion to decide eligibility or interpret the plan. We could not confirm whether state law limits that discretion. The court may award reasonable attorney's fees and costs to either side.
- Your deadline
- ERISA sets no deadline for a benefit lawsuit, but your plan document may set its own if it is reasonable, even one that starts before the appeals end. Read the plan document now. You do not have to use the state external review process before suing. Check the date on your notice, which controls.
- Their deadline
- Set by the court.
- What to send
- A lawyer files the suit. Put your records, your doctor's letter and your arguments in the appeal itself; do not count on adding them later in court.
- If you lose, or hear nothing
- State-law claims for damages over a benefit denial are generally preempted (overridden) for employer plans under ERISA.
- The rule
- ERISA section 502, 29 U.S.C. 1132
If waiting could harm your health
If waiting could seriously harm your health, ask for an urgent appeal. The insurer must decide within 72 hours. If a doctor who knows your condition says the claim is urgent, the insurer must treat it as urgent. You can ask for an urgent independent review at the same time as the urgent appeal. An urgent appeal may be requested by phone or in writing.
Free help for this coverage
- Your state insurance department
Answers questions and takes complaints about insurers and their policies. Find yours in the National Association of Insurance Commissioners directory.
- Your state Consumer Assistance Program
HealthCare.gov says these programs can help you appeal, and can file an appeal for you. The Centers for Medicare & Medicaid Services (CMS) list gives contacts by state; it says no program receives federal grant money as of its September 2024 update, so confirm your state's listing is current.
- Department of Labor benefits advisors
Free help at 1-866-444-3272 for questions about private employer plans, including a plan that broke the claims rules.
- Patient Advocate Foundation case management
Free one-on-one help for patients who qualify, by phone at 1-800-532-5274, Monday to Friday, 8:30 a.m. to 5:00 p.m. Eastern (hours as listed in November 2026). It has limits on how many people it can take each day.
Who this covers
This page is for you if your employer or union buys a health insurance policy for its workers. The insurance company pays the claims and carries the cost. Because the policy is insurance, state insurance law applies to the insurer as well as the federal employer-plan rules.
How to tell this is your coverage
Use the steps in the list above. The summary plan description and your human resources department are the best sources. If they say the plan is “insured” or that benefits are provided under a policy, you are here. If they say the employer pays claims itself, read the page for self-funded employer plans instead.
What does not apply to you
If your plan is grandfathered (in place on 23 March 2010 and not changed in disqualifying ways), the general external review right does not apply, except for surprise-billing denials. See the page for grandfathered plans. If your employer is a state or local government, see the page for government employer plans, because the lawsuit rules differ.
Where people go wrong
- Assuming the insurer’s name on the card means the plan is insured. Check with the plan document.
- Using the state external review process to skip the appeal. Finish the internal appeal unless you qualify for an urgent review or the insurer broke the appeal rules.
- Treating the state complaint as an appeal. A complaint does not stop your deadlines.
Sources
- 29 CFR 2590.715-2719, internal claims and appeals and external review
- 29 CFR 2560.503-1, claims procedure
- 29 CFR 2520.102-3, contents of the summary plan description
- ERISA section 514, 29 U.S.C. 1144
- Rush Prudential HMO, Inc. v. Moran, 536 U.S. 355 (2002)
- ERISA section 502, 29 U.S.C. 1132
- Which states use which external review process
- HealthCare.gov, internal appeals
- Filing a Claim for Your Health Benefits
- Search Form 5500 filings
- Ask EBSA, request help from a benefits advisor
- State insurance departments directory
- Consumer Assistance Program
- Patient Advocate Foundation case management