Internal appeal vs external review: the two steps after a denial

If your plan refuses to approve or pay for care, it must tell you why in writing. You can ask the plan to look again. This is called an internal appeal.

Checked against official sources: October 30, 2026.

Step 1: appeal to your plan

  • You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal. Your plan can give you more time, not less.

    Law: 29 CFR 2560.503-1(h)(3)(i); 45 CFR 147.136(b)(2)(i), (b)(3)(i)

  • Use your plan's appeal form, or write to the plan with your name, claim number and member ID number. Add anything you want the plan to consider, such as a letter from your doctor. Keep copies of everything.

    Law: HealthCare.gov, Internal appeals

  • The plan must decide your appeal within 72 hours for urgent care, 30 days for care you have not received yet, and 60 days for care you already received. If an employer plan has two appeal levels, each level must be decided within 15 days (care not yet received) or 30 days (care already received).

    Law: 29 CFR 2560.503-1(i)(2)

  • A plan you bought on your own (individual market) may have only one level of internal appeal.

    Law: 45 CFR 147.136(b)(3)(ii)(G)

  • The denial notice must identify the claim (date of service, provider, amount), give the reason and denial code, describe the standard the plan used, explain how to appeal and ask for external review, and list your state's consumer assistance office if there is one.

    Law: 45 CFR 147.136(b)(2)(ii)(E)

Ask for your claim file

  • You can ask for, free of charge, copies of all documents, records and other information relevant to your claim.

    Law: 29 CFR 2560.503-1(h)(2)(iii)

  • If the plan used an internal rule, guideline or protocol, you can get a free copy of it. If the denial was for medical necessity or experimental treatment, you can get a free explanation of the clinical reasons applied to your case.

    Law: 29 CFR 2560.503-1(g)(1)(v)

  • You can ask for the diagnosis code and treatment code (and what they mean) for a denied claim. Asking for codes does not count as starting an appeal.

    Law: 45 CFR 147.136(b)(2)(ii)(E)(2)

Step 2: outside (external) review

  • External review covers denials that involve medical judgment (for example "not medically necessary", level of care, or setting), denials of treatment as experimental or investigational, cancelling your coverage back to its start date (rescission), and whether the plan followed the No Surprises Act billing protections. A denial because you are not eligible under the plan's terms does not qualify for the federal process.

    Law: 45 CFR 147.136(a)(2)(i), (d)(1)(i); HealthCare.gov, External Review

  • Under the federal process you have 4 months from the date you receive the denial or final appeal decision to ask for external review. If there is no matching date 4 months later, the deadline is the first day of the fifth month. If the last day is a Saturday, Sunday or federal holiday, it moves to the next business day. State programs must allow at least 4 months; some allow more.

    Law: 45 CFR 147.136(c)(2)(vi), (d)(2)(i)

  • The reviewer must decide within 45 days of getting a standard request, and within 72 hours for an expedited (urgent) request.

    Law: 45 CFR 147.136(c)(2)(xii)-(xiii), (d)(2)(iii)(B)(6), (d)(3)(iv)

  • The decision is binding on the plan. If the reviewer rules for you, the plan must cover or pay right away.

    Law: 45 CFR 147.136(c)(2)(xi), (d)(2)(iv)

  • 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

  • If your state's program meets federal standards, insurance companies in your state use it. If not, the federal HHS process applies, or the insurer contracts with independent review organizations. Your denial notice must say who handles your review.

    Law: 45 CFR 147.136(c), (d); HealthCare.gov, External Review

When you can skip ahead

  • If the plan does not follow the appeal rules for your claim, you may be treated as having finished the internal appeal. You can then go to external review or to court. Small, harmless mistakes by the plan do not count.

Law: 45 CFR 147.136(b)(2)(ii)(F)

Outside review in your state

States with their own outside review program

States that use the federal process

More →

Before you act

Ask your plan for the denial in writing, with the reason and the deadline. Write the date you got it on a calendar, ask for your claim file, and write down the date and name of everyone you speak with.

Quick answers

How long do I have to appeal a denied health claim?

You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal. Your plan can give you more time, not less.

How long do I have to ask for an outside review?

Under the federal process you have 4 months from the date you receive the denial or final appeal decision to ask for external review.

Does outside review cost money?

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.

Is the outside review decision final?

The decision is binding on the plan. If the reviewer rules for you, the plan must cover or pay right away.

Free help

Free help can look at your denial and your letters. Consumer assistance programs, legal aid groups and state insurance departments do not charge for this.

Free calculator and letters

Appeal deadline calculator

Letter: appeal to your plan

Letter: ask for external review

Letter: Medicaid fair hearing request

Sources