Health insurance or Medicaid said no in Georgia? Deadlines and free help

In Georgia, your health plan is regulated by Georgia Office of Commissioner of Insurance and Safety Fire (OCI), Consumer Services Division, if it is a state-regulated plan.

Georgia uses the federal process for independent review of denials. You have 4 months to ask for it.

External review means a doctor or reviewer outside your plan decides again. Internal appeal means your plan looks at its own decision again.

Pick your plan type

Which kind of coverage was denied? The plan type decides which rules and deadlines apply.

Insurance I bought or got through work

Your state insurance rules may apply. First appeal to your plan, then ask for an outside review.

My employer pays claims itself (self-funded)

Federal rules apply, and most state insurance laws do not. Free help comes from the U.S. Department of Labor.

Georgia Medicaid

You ask the state for a fair hearing. In a Medicaid health plan, you usually appeal to the plan first.

Marketplace (Georgia Access) decision

A decision about whether you can buy a plan or get financial help is appealed to the Marketplace.

How long do I have?Urgent care: faster decisionWrite my appealFree help

Checked against official sources: October 30, 2026.

Appeal deadlines are strict. If you are near a deadline or your care is urgent, call free help today.

How long do I have in Georgia?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months (federal rule) — The date you receive the plan's final internal appeal denial (federal rule)
Hearing deadline
30 days — The date of the notice (notification of the decision you disagree with)
Keeping your benefits during the appeal
If you ask, your Medicaid (and your patient liability or cost share) can continue while you wait for the hearing if DFCS receives your request within 10 days of the date of the notice.
Appeal to the plan first
60 days (federal rule)
Appeal deadline – Georgia Access
90 days

How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

Many large employers pay claims themselves through self-insured plans, even when an insurance company administers them; federal law exempts those plans from state insurance regulation. If you are covered by an HMO, call OCI for help, even if your policy might otherwise be outside its reach.

Step 1: Appeal to your plan in Georgia

What it is called: Grievance (internal appeal) with your plan or insurer

Time to file

Use the deadline on your denial notice. Federal rules give at least 180 days for most plans.

Law: O.C.G.A. 33-20A-5 (as cited in Ga. Comp. R. & Regs. 120-2-111-.02)

Georgia law requires managed care plans to have a grievance procedure. Ask your plan for its grievance and appeal rules in writing. The federal internal appeal rules and decision times apply.

Law: O.C.G.A. 33-20A-5; O.C.G.A. 33-20A-5 (as cited in Ga. Comp. R. & Regs. 120-2-111-.02)

Step 2: Outside review in Georgia

Program

Federal external review (HHS-administered process)

Who runs it
  • U.S. Department of Health and Human Services (HHS) federal external review process: Insured health plans and HMOs in Georgia, and self-insured non-federal government plans
  • Georgia Office of Commissioner of Insurance and Safety Fire, Administrative Procedure Department (state Patient's Right to Independent Review Act; assigns a certified independent review organization): Members of managed care plans (such as HMOs) after the plan's grievance process; your plan's final grievance notice must say whether and how to use it
Deadline to ask

Federal rule: at least 4 months.

Georgia uses the federal external review process. Follow the deadline on your final denial notice; the federal rule is 4 months.

The deadline runs from

The date you receive the plan's final internal appeal denial (federal rule)

Do I have to appeal to my plan first?

Follow the federal rules: you usually must finish the plan's internal appeal first, unless your case is urgent or the plan did not follow the appeal rules.

Cost

Under the federal process, a fee of up to $25 may apply (see the national rules).

Federal rule: The HHS-administered federal process is free. A state program or a plan's contracted reviewer may charge a fee, but not more than $25.

Law: HealthCare.gov, External Review

What can be reviewed

Under the federal process: denials based on medical judgment (such as medical necessity, appropriateness, level of care or effectiveness), experimental or investigational treatment, and rescissions of coverage.

Is the decision final?

Under the federal process, the decision is binding on the plan.

How to ask

Follow the instructions in your plan's final denial notice. For the HHS-administered federal process, use the national contact details. If you are in a managed care plan and its final grievance notice offers Georgia's state independent review, send a written request with your name and address and a copy of the plan's grievance decision to: Attn: Administrative Procedure Department, Georgia Office of Commissioner of Insurance and Safety Fire, 2 Martin Luther King Jr. Drive, West Tower, Suite 704, Atlanta, GA 30334. The plan must include the state request forms with its notice. Under the state rule the reviewer decides within 15 working days after the time for sending more information ends, or within 72 hours after receiving the documents if your treating provider says your health is at risk.

Law: Ga. Comp. R. & Regs. 120-2-111-.04 to -.06; DCH, Managed Care Patient's Rights (HB 1013, 2022)

HHS-Administered Federal External Review Process (MAXIMUS)

Only for plans that use the HHS-administered process. Ask your plan, or check your denial notice, to find out.

maximusferp.my.site.com · 1-888-866-6205 · MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534

Urgent care in Georgia: faster decisions

Outside review

Expedited federal external review is available for urgent cases under the federal rules.

Law: Ga. Comp. R. & Regs. 120-2-111-.04 to -.06; DCH, Managed Care Patient's Rights (HB 1013, 2022)

Complaints about your plan in Georgia

First ask your insurance company to fix the problem and keep records of every call and letter. If that does not work, file a complaint with the OCI Consumer Services Division, fastest through its online Consumer Complaint Portal. Include your contact details, the insurance company's exact name, your policy and claim numbers, a copy of both sides of your insurance card, a short description of the problem and copies (not originals) of your papers.

gov.sircon.com

Medicaid (Georgia Medicaid (including Georgia Families managed care, PeachCare for Kids and Georgia Pathways to Coverage)) denials in Georgia

Who holds the hearing: Georgia Office of State Administrative Hearings (OSAH).

Hearing deadline: 30 days

All the details →

Marketplace decisions in Georgia

Marketplace

Georgia Access · 1-888-687-1503 (TTY 711)

Appeal deadline

90 days

The date on the Eligibility Determination Notice (95 calendar days for citizenship- or immigration-related issues)

How to appeal

Fill out the Georgia Access Consumer Appeal Request Form and add supporting papers. Upload it to your account through the Georgia Access enrollment channel you used (Georgia Access, your certified agent, web broker or insurance company), give it to your certified agent, or mail it to Georgia Access Contact Center, Attn: Consumer Appeal Request, PO Box 12264, Birmingham, AL 35202. If you missed the deadline, explain why in writing with your request; you may get a good-cause extension.

Form

Georgia Access Consumer Appeal Request Form (PY2025)

Coverage while you appeal

Depending on the reason for your appeal, you may be able to keep your coverage and your premium tax credits or cost-sharing reductions while the appeal is processed. Georgia Access sends a notice if you qualify. You may have to pay back tax credits you were not eligible for.

If you disagree

If you disagree with the state appeal hearing decision, you can take it to a federal appeal hearing; the steps are in your notice.

Law: Georgia Access Consumer Appeal Request Form Information Sheet (published 10/1/2024); Georgia Access Consumer Appeal Request Form Information Sheet (published 45 CFR 155.520

Other rights in Georgia

Georgia Pathways to Coverage (work requirement)

Georgia Pathways covers some adults who report qualifying activities, such as work, job training, education or community service. You report your hours at application and at annual renewal. You have 30 days from the date of a Pathways denial to ask for a fair hearing at OSAH.

Mental health parity complaints about Medicaid

DCH has an online portal for mental health parity complaints about Medicaid (including Georgia Pathways), PeachCare for Kids or the State Health Benefit Plan. Parity complaints about other plans go to the Office of Commissioner of Insurance and Safety Fire.

State independent review for managed care plans

Georgia's Patient's Right to Independent Review Act still lets members of managed care plans ask for an independent review after the plan's grievance decision. Since July 1, 2022, requests go to the Office of Commissioner of Insurance and Safety Fire. The reviewer must decide in writing within 15 working days after the time for sending information ends, or within 72 hours (expedited) after getting the documents when your treating provider says waiting would put your life or health at risk.

Law: Ga. Comp. R. & Regs. 120-2-111-.04 to -.06

How long do I have? Deadline calculator

Pick your plan type and enter the dates on your notice. We count from the rules in Georgia and the federal rules.

Worked out in your browser. Nothing you enter here is saved or sent.

If you are not sure when it arrived, use the date printed on the notice. That date is never later than the day it arrived.

Choose what was decided and enter the date on your notice

We add the number of days or months from the law to your date. Nothing is saved.

Write my appeal: free letters

Free help in Georgia

Good to know in Georgia

  • Georgia does not run its own external review program; insured plans use the HHS-administered federal process (CMS CCIIO, State External Appeals Review Processes).
  • Georgia gives only 30 days from the date of the notice to ask for a Medicaid fair hearing.
  • Every OSAH judge's decision is final and can only be challenged by a petition for judicial review in superior court, filed within 30 days after service of the decision.

Changes in 2024–2026

Plan year 2025 (open enrollment from November 1, 2024): Georgia Access, run by the Office of Commissioner of Insurance and Safety Fire, replaced HealthCare.gov as Georgia's Marketplace, and Marketplace eligibility appeals now go to Georgia Access and the OCI Administrative Procedure Division. Georgia Pathways to Coverage, Georgia's Medicaid work-requirement program for some adults, started before the 2027 federal rules; members now report qualifying hours at application and annual renewal.

Questions about appeals in Georgia

How long do I have to appeal a health insurance denial in Georgia?

Use the deadline on your denial notice. Federal rules give at least 180 days for most plans. You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal.

How do I get an outside (external) review in Georgia?

Follow the instructions in your plan's final denial notice. For the HHS-administered federal process, use the national contact details.

Is outside review free in Georgia?

Under the federal process, a fee of up to $25 may apply (see the national rules).

How long do I have to ask for a Medicaid fair hearing in Georgia?

30 days. The date of the notice (notification of the decision you disagree with)

Can I keep my Medicaid benefits while I appeal in Georgia?

If you ask, your Medicaid (and your patient liability or cost share) can continue while you wait for the hearing if DFCS receives your request within 10 days of the date of the notice. DFCS allows 12 days from the postmark if you have the envelope, or 14 days from the date on the notice if you do not.

How do I appeal a Marketplace decision in Georgia?

Fill out the Georgia Access Consumer Appeal Request Form and add supporting papers. Upload it to your account through the Georgia Access enrollment channel you used (Georgia Access, your certified agent, web broker or insurance company), give it to your certified agent, or mail it to Georgia Access Contact Center, Attn: Consumer Appeal Request, PO Box 12264, Birmingham, AL 35202.

Not about a denied claim?

Nearby states

Sources

Sources