How to file an internal appeal

An internal appeal is your written request that your plan look at its decision again. For job-based plans and individual or marketplace plans that are not grandfathered, you have at least 180 days from the day you receive the denial notice to file it. Your plan may give you more time. Check the date on your notice, which controls. File in writing, send proof, and keep the copy.

What this means

The plan that denied your claim reviews it a second time. This step is free. The plan cannot charge a fee to file an appeal.

A grandfathered plan (one in place since March 2010 that has kept its old status) still follows the basic claims rules if it is an employer plan, including the 180 days and the decision deadlines on this page. What it may lack are the extra protections described on the page about how external review works.

The rules give you real protections in this step. The reviewer cannot be the person who made the first decision or that person’s subordinate, and must give no deference to the first decision. If the denial rests on a medical judgment, the plan must consult a health care professional with training in that field who was not involved the first time. You may send written comments, documents and records, and the reviewer must consider all of it, including anything the first decision never saw.

What to do

1. Find the deadline on your notice. The notice must describe the review procedures and time limits. Write the date down. The federal rule counts the 180 days from when you receive the notice, but you cannot always prove that date, so count from the date printed on it to be safe. See how deadlines are counted.
2. Ask for your claim file (your step). You are entitled to it free of charge, along with the clinical rule the plan used. Use the claim file request letter. Do not wait for it if your deadline is close. File the appeal, and add the file later.
3. Ask your doctor for a letter (your doctor’s step). A strong letter answers the plan’s stated reason. Give the office the denial notice and a date to send it by. See how to ask your doctor for a letter.
4. Write the appeal. Say what you are appealing, why the plan is wrong, and what you want. Ask for the decision in writing. The appeal letter builder helps, and the page on writing an appeal letter explains each part.
5. Send it so you can prove the plan got it. Use the address in your notice. Choose certified mail with a return receipt, a fax with a confirmation page, or the plan’s portal with a saved confirmation. Keep a full copy. See how to assemble and send the packet.
6. Mark the decision date. Count from the day you file. Note the day you expect an answer, and call if it passes.
7. Ask to see anything new before the final decision. A plan that is not grandfathered must give you any new evidence or reason it relies on, free, in time for you to respond.

How long the plan has to decide

These are the federal limits for a group health plan. Counting starts when you file under the plan’s reasonable procedures, even if you have not sent everything.

Type of claim	The plan must decide within
Urgent care	As soon as possible, and no later than 72 hours
Pre-service (you need approval before the care)	30 days
Post-service (the care or bill has already happened)	60 days

If your plan has two levels of appeal, each level has half of the 30 or 60 days: 15 days for pre-service, 30 days for post-service. An urgent appeal is still 72 hours at each level. The rules give group health plans no extension on appeal, except that certain multiemployer plans whose boards meet on a schedule may use that schedule. If the date passes without an answer, see when the plan misses its deadline.

What the plan may say, and what to say back

“We did not receive your appeal.” Send proof of delivery, such as the return receipt or fax confirmation, and ask the plan to log the original filing date.

“Your appeal is late.” Compare the date you received the notice with the plan’s own time limit, which may be longer than 180 days. Ask the plan to name the document that sets its limit.

“Your doctor cannot appeal for you.” A plan must allow an authorized representative to act for you, and in an urgent case a health care professional who knows your condition. Send the plan’s form or a signed note naming your representative.

The rule

A group health plan must allow a claimant at least 180 days after receiving a denial notice to appeal, must decide within 72 hours (urgent), 30 days (pre-service) or 60 days (post-service), and must give the claimant a full and fair review by someone other than the first decider. The same 180-day minimum carries over to individual coverage that is not grandfathered. See title 29 of the Code of Federal Regulations (CFR), section 2560.503-1(h) and (i) and 45 CFR 147.136(b)(3).

Watch for

• One level or two. A group health plan may require up to two appeals before you can go to court. An insurer selling individual coverage must offer only one internal level. Your notice says how many your plan has.
• Your plan may call it something else. Words such as grievance, reconsideration or request for review can mean an appeal. Use the name on your notice and say “appeal” in your letter.
• Deadlines for public coverage are different. Medicare, Medicaid and military coverage use their own steps. Start at the page for Medicare or Medicaid and children’s coverage.
• Do not skip the next step. If this appeal is denied, you will usually have four months to ask for outside review. See the next pages.

What next

• How to get an expedited appeal: the faster route when waiting could harm your health.
• Second-level internal appeals: what to do if your plan has a second internal step.
• How external review works: the independent review you can ask for after a final internal denial.