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Part of: Your coverage

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The rules depend on your plan.
Find yours first.

Two people with the same denial can have different deadlines, different reviewers and different agencies to call, because their coverage is regulated differently. Pick your coverage to see your own steps.

Not sure what kind of plan you have? Find out.

What do you need to do?

  1. Job-based plans Coverage through an employer or union, whether the employer funds it or buys it from an insurer.
  2. Marketplace and individual plans Coverage you buy yourself, through HealthCare.gov, a state marketplace or directly from an insurer.
  3. Medicare, Medicare Advantage and drug plans Original Medicare, Medicare Advantage plans, Part D drug plans and Medigap.
  4. Medicaid and children's coverage Medicaid, Medicaid managed care plans and the Children's Health Insurance Program.
  5. Military, veteran and federal employee coverage TRICARE, Veterans Affairs health care, federal employee plans and the Indian Health Service.
  6. Student, short-term and other coverage Student health plans, short-term plans, sharing ministries and other products with fewer protections.

Tools for this step

 2 tools

Free, no account, nothing leaves your browser.

  • Medicaid hearing planner

    Work out the order of steps, the deadlines that apply, the earlier deadline to keep your services going, and how to prepare for a fair hearing.

    Tool

  • Medicare appeal navigator

    Find your level in the Medicare appeal process, the next level, the form and the time limit.

    Tool

Start with

 19 guides

19 guides in this area

More guides 16
  • Children's Health Insurance Program appeals

    Your child's separate Children's Health Insurance Program plan denied something. Ask for an independent review, not a Medicaid fair hearing. Here is what the federal rules do and do not promise.

  • Fast appeals when a hospital or facility is ending your care

    A hospital says you are being discharged, or a nursing facility, home health agency, rehabilitation facility or hospice says Medicare coverage is ending. You can ask for a fast review. Time of day matters.

  • Federal employee plan appeals

    How to appeal a Federal Employees Health Benefits plan denial. Ask the carrier to reconsider within 6 months. Then ask the Office of Personnel Management to review. We also explain what a lawsuit looks like.

  • Marketplace and individual plans: the appeal path

    How to appeal a denial from a plan you bought yourself. It may be through HealthCare.gov, a state marketplace or an insurer directly. You appeal to the plan, then to independent review.

  • Marketplace eligibility appeals are not claim appeals

    A Marketplace appeal challenges a decision about your eligibility or tax credit. It cannot overturn an insurer's claim denial. Learn what it covers, the 90-day deadline, and what to do for a claim denial instead.

  • Medicaid appeals and fair hearings

    How to challenge a Medicaid denial, cut or ending of benefits in a state fair hearing. Learn what notice you must get, how to keep benefits going, and why your state's deadline matters most.

  • Medicaid managed care: the plan appeal comes first

    If a Medicaid health plan denies or cuts a service, you appeal to the plan within 60 days. Only after that can you ask the state for a fair hearing. Here is the order and how to keep benefits going.

  • Medicare Advantage appeals

    How to appeal when a Medicare Advantage plan refuses to approve or pay for care. Learn the 65-day deadline, the plan's decision times (including the 2026 prior authorization rule) and the automatic outside review.

  • Medicare drug plan appeals and exceptions

    What to do when a Medicare drug plan will not cover a prescription. Ask for a coverage decision or an exception, then appeal. The outside review step is not automatic.

  • Medicare observation status

    If a hospital admitted you and then changed you to observation, you may have a right to appeal that change, but only before you leave the hospital. Learn who qualifies, what notice to expect and what has closed.

  • Original Medicare: the five appeal levels

    A plain walk through the five levels of a Medicare Parts A and B appeal. It starts from the Medicare Summary Notice. It names the deadlines that trip people up and what to do first.

  • Student, short-term and other coverage with fewer rights

    Student plans, short-term plans, sharing ministries and fixed indemnity products carry different appeal rights. Learn which federal protections apply, which do not, and where to start when a claim is denied.

  • TRICARE appeals

    How to appeal a TRICARE denial. Start with a written reconsideration within 90 days. Next steps differ for factual and medical necessity denials, with dollar minimums at the later levels.

  • Two plans at once and COBRA

    A short guide to claims stuck between two health plans and to continuation coverage after a job change. It explains what this site can and cannot confirm, and who to ask.

  • Veterans Affairs health care and community care denials

    Veterans Affairs uses two different routes for health care disputes: a clinical appeal for treatment decisions and a decision review for benefit and payment decisions. Pick the right one first.

  • What a Medicaid fair hearing is like

    A calm walk through a Medicaid fair hearing. Learn how to prepare, what happens on the day, and what the agency's lawyer does. Know the rights federal rules give you.

Letters, checklists and programs

 4 items
  • Medicare appeal

    The notices to look for, the forms and the deadlines at each level of a Medicare appeal, including fast appeals for hospital discharge and ending services.

    Checklist

  • Phone script: talk to human resources

    What to ask your employer's benefits or human resources office to learn who runs your plan and to get the plan documents.

    Letter or script

Programs and services 2

Run by other organizations. We summarize them and say when we last checked.

  • Program or service

    Disability Rights Florida guide to Medicaid fair hearings

    A step-by-step explanation of how to challenge a denial or reduction of Medicaid services in Florida, from notice to petition to hearing. For people with disabilities. Florida only.

    From Disability Rights Florida

  • Program or service

    Form 5500 search: look up your employer plan's annual report

    A Department of Labor search of the annual reports (Form 5500) that many employer plans file. A search can help you work out whether your employer plan is insured or pays claims itself.

    From U.S. Department of Labor, EFAST2 filing system

Your next step may connect

  • Understand your denial

    Work out what was refused, why, which rules apply to you, and by when you must act.

  • Appeal

    File the appeal, get a fast decision when health is at risk, and take it outside the plan if it says no again.