Urgent appeals: when you cannot wait

Urgent appeal to your plan

• If your doctor says your case is urgent, the plan must treat it as urgent.

  Law: 45 CFR 147.136(b)(2)(ii)(B); 29 CFR 2560.503-1(m)(1)(iii)

• 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)

• If the plan wants to cut or stop an ongoing course of treatment it already approved, it must tell you in advance so you can appeal first. Coverage must continue while the appeal is pending.

  Law: 45 CFR 147.136(b)(2)(iii); 29 CFR 2560.503-1(f)(2)(ii)

Urgent outside review

• If your situation is urgent, you can ask for an expedited external review at the same time as an expedited internal appeal. You can also ask for one if you are still in the hospital after emergency care.

  Law: 45 CFR 147.136(d)(3)(i); HealthCare.gov, Internal appeals

• 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)

Urgent Medicaid hearings and plan appeals

• States must offer an expedited hearing when the normal timeline could put your life, health or ability to regain maximum function at risk.

  Law: 42 CFR 431.224(a)

• The state must ordinarily make a final decision within 90 days of your hearing request. If you first appealed to a Medicaid managed care plan, the 90 days count from the date you filed the plan appeal, not counting the days you took to ask for the hearing. Expedited hearings about a denied service from a managed care plan must be decided within 3 working days after the state gets the plan's case file.

  Law: 42 CFR 431.244(f)(1)-(2)

Medicaid health plans: prior authorization

• For Medicaid and Medicaid managed care plans, since 2026 a request for prior approval of an item or service (not drugs) must be decided within 7 calendar days, or 72 hours if urgent. The 7 days can be extended by up to 14 days. State law may set shorter times.

Law: 42 CFR 438.210(d)(1)(i)(B), (d)(1)(ii), (d)(2); 42 CFR 440.230(e)(1)

Urgent Marketplace appeals

• You can ask for a faster (expedited) appeal if waiting could seriously put your health at risk. Explain the health reason when you file.

  Law: 45 CFR 155.540; HealthCare.gov, Getting a faster appeal

• The appeals entity must send a written decision within 90 days of receiving a valid appeal, as administratively feasible. If a state Marketplace appeal goes against you, you can appeal to HHS within 30 days.

  Law: 45 CFR 155.545(b)(1); 45 CFR 155.520(c)

Before you act

Ask your doctor for a short letter that says why waiting would harm your health, and send it with your appeal. Call the plan, then confirm in writing.

Quick answers

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.

• Your state's Consumer Assistance Program (CAP) or insurance department
• U.S. Department of Labor, Employee Benefits Security Administration (EBSA) · 1-866-444-3272
• HealthCare.gov Marketplace Call Center and local help · 1-800-318-2596
• CCIIO Health Insurance Assistance Team · 1-888-393-2789
• Legal Services Corporation (LSC) - Find legal aid
• LawHelp.org
• LawHelp.org

Free calculator and letters