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

In Illinois, your health plan is regulated by Illinois Department of Insurance (IDOI), Office of Consumer Health Insurance, if it is a state-regulated plan.

Illinois runs its own independent review of denials: External Review (Health Carrier External Review Act). You generally 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.

Illinois Medicaid

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

Marketplace (Get Covered Illinois) 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 Illinois?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months
Hearing deadline
60 days
Appeal to the plan first
60 days
Then a state hearing
120 days
Appeal deadline – Get Covered Illinois
90 days

All the details →

How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

Not all health plans are under the IDOI. If you are covered by a self-insured employer, union, church or non-federal governmental plan, a group plan issued in another state, or Medicare, Medicaid, FEHB, TRICARE or other military coverage, your plan follows a different process; check your benefit booklet.

Step 1: Appeal to your plan in Illinois

What it is called: Health care services appeal (internal appeal) with your health plan

For a managed care plan, if a denial could significantly increase the risk to your health (including an ongoing course of treatment), you can appeal by phone or in writing. The plan must tell you within 24 hours what information it needs and decide within 24 hours after it gets that information. For other appeals, the plan must tell you within 3 business days what it needs and decide within 15 business days after it gets the information. A clinical peer who was not involved in the first decision must review the appeal, and the written decision must give clear reasons, the medical criteria used, and how to ask for external review.

Law: 215 ILCS 134/45(b)-(e) (Managed Care Reform and Patient Rights Act)

All the details →

Step 2: Outside review in Illinois

External Review (Health Carrier External Review Act)

Deadline to ask: 4 months.

All the details →

Urgent care in Illinois: faster decisions

Appeal to your plan

  • Your plan must decide an urgent appeal within 24 hours.

Outside review

You can ask for expedited review, by phone or in writing, if the time for a standard review would seriously jeopardize your life or health or your ability to regain maximum function, if you got emergency care and have not been discharged, or if experimental treatment would be significantly less effective if not started promptly. Your doctor must complete the IDOI physician certification form. The reviewer must decide within 72 hours, or within 48 hours after receiving the clinical reviewers' opinions for experimental treatment. If the plan does not decide an expedited internal appeal within 48 hours, you can go straight to external review. When you ask for expedited review you give up any remaining plan appeal steps, and you will not get another chance to send more information, so send everything with the form.

Law: 215 ILCS 180/20, 25, 30, 35, 40, 42, 45, 70

Marketplace

If you need health services now and a delay could seriously jeopardize your life, health, or ability to attain, maintain or regain maximum function, you can ask for an expedited appeal by calling 1-866-311-1119 and explaining the urgency on the form.

Law: Get Covered Illinois Appeal Request Form (3-18-26), instructions 7-8; 45 CFR 155.520

Complaints about your plan in Illinois

For other problems with a plan the IDOI regulates, you can file a complaint online through the IDOI Help Center, or send the Consumer Health Care Complaint Form by email to DOI.complaints@illinois.gov, by fax to 217-558-2083, or by mail to the Office of Consumer Health Insurance, 4800 Wabash Avenue, Springfield, IL 62711. If a plan says your request is not eligible for external review, you can appeal that to the IDOI by filing a complaint.

Law: 215 ILCS 180/35(c)

idoihelpcenter.illinois.gov

Medicaid (Illinois Medicaid (medical assistance, including All Kids and HealthChoice Illinois managed care plans)) denials in Illinois

Who holds the hearing: IDHS Bureau of Hearings (eligibility: denials, terminations, spenddown and other case actions, and some waiver and behavioral health services); HFS Bureau of Administrative Hearings (medical services and items, including appeals after a managed care plan decision).

Hearing deadline: 60 days

All the details →

Marketplace decisions in Illinois

Marketplace

Get Covered Illinois · 1-866-311-1119 (TTY 711)

Appeal deadline

90 days

The date on your eligibility notice

Source: notice of determination

How to appeal

Fill out the Get Covered Illinois Appeal Request Form and send it online, by fax to 1-888-973-8254, or by mail to Get Covered Illinois, Attn: Marketplace Appeals Program, P.O. Box 804058, Chicago, IL 60680. You can also call 1-866-311-1119. The filing date is the date sent online or by fax, or the postmark date. A hearing officer hears the appeal.

Source: log in, go to My Tickets, submit a ticket with the subject "Marketplace Appeal" and attach the form

Form

Get Covered Illinois Appeal Request Form (3-18-26)

Faster appeal

If you need health services now and a delay could seriously jeopardize your life, health, or ability to attain, maintain or regain maximum function, you can ask for an expedited appeal by calling 1-866-311-1119 and explaining the urgency on the form.

Coverage while you appeal

If you are appealing a termination of coverage or an eligibility redetermination, you can ask to keep your plan and financial help while the appeal is pending (Continued Enrollment) at any time during the appeal, using the Continued Enrollment Form. Continued Enrollment requires that your appeal be accepted.

If you disagree

If you disagree with the final decision, you can appeal to the U.S. Department of Health and Human Services within 30 days of the decision (Health Insurance Marketplace, Attn: Appeals, 465 Industrial Boulevard, London, KY 40750-0061; 1-800-318-2596, TTY 1-855-889-4325), or file in an Illinois circuit court within 35 days of receiving the decision.

Law: Get Covered Illinois Appeal Request Form (3-18-26), instructions 7-8; 45 CFR 155.520

Other rights in Illinois

How fast a plan must decide a prior approval

A health insurer must decide a non-urgent prior authorization request no later than 5 calendar days after it has all the information it needs, and an urgent request no later than 48 hours after it has the information. A prior approval for a recurring service or maintenance drug for a chronic condition stays valid for up to 12 months.

Law: 215 ILCS 200/25, 200/30, 200/65 (Prior Authorization Reform Act)

Who decides medical necessity and automated tools

Even if a plan uses an automated or algorithm-based process in utilization review, only a clinical peer may make a denial based on medical necessity, and only a clinical peer may review your appeal. When a doctor appeals, the appeal must be reviewed by a physician in the same or a similar specialty.

Law: 215 ILCS 134/45(i) (P.A. 103-656, eff. 1-1-25); 215 ILCS 200/45

Prescription drug exceptions

You or your prescriber can ask your insurer to cover a drug that is not on the formulary, is being dropped, or is limited by a dose restriction. The insurer must approve or deny the request within 72 hours, or within 24 hours for an expedited request, and must say why if it denies it and how to appeal.

Law: 215 ILCS 134/45.1

How long do I have? Deadline calculator

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

Good to know in Illinois

  • In Illinois the health plan pays the whole cost of an external review; you pay nothing.

    Law: 215 ILCS 180/70

  • If your plan has not decided an expedited internal appeal within 48 hours, you can go straight to external review.

    Law: 215 ILCS 180/30(b)(2)

  • Illinois gives 60 days, not 90, to ask for a Medicaid fair hearing on an IDHS eligibility action.

    Law: 89 Ill. Adm. Code 14.10(f)(1)

Changes in 2024–2026

January 1, 2025: P.A. 103-656 added a rule that, even when a plan uses an automated process for utilization review, only a clinical peer may deny care as not medically necessary or review an appeal. Plan year 2026 (open enrollment from November 2025): Illinois runs its own state-based Marketplace, Get Covered Illinois, a division of the Illinois Department of Insurance, which now handles Marketplace eligibility appeals. In 2026 the IDOI moved its Springfield office to 4800 Wabash Avenue, Springfield, IL 62711.

Law: 215 ILCS 134/45(i)

Source: Get Covered Illinois appeal form dated 3-18-26; external review form revised 6/2026

Questions about appeals in Illinois

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

State law does not set a longer time to file. 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 Illinois?

External Review (Health Carrier External Review Act). Send the Request for External Review form to the IDOI online through the IDOI Help Center, by email to DOI.externalreview@illinois.gov, by fax to 217-557-8495, or by mail to Illinois Department of Insurance, 4800 Wabash Avenue, Springfield, IL 62711. Attach a copy of the final denial letter (for expedited review, the latest denial letter), a copy of your insurance ID card, and any medical records or other papers you want the reviewer to see.

Is outside review free in Illinois?

External review is free for you. The health plan pays the full cost.

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

60 days. The date of the Department's notice of the action

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

Your benefits continue at the previous level if you file your appeal by the later of the date of the change or the 10th calendar day after the date of the notice. If that day is not a workday, an appeal received or postmarked by the next workday counts.

How do I appeal a Marketplace decision in Illinois?

Fill out the Get Covered Illinois Appeal Request Form and send it online, by fax to 1-888-973-8254, or by mail to Get Covered Illinois, Attn: Marketplace Appeals Program, P.O. Box 804058, Chicago, IL 60680. You can also call 1-866-311-1119.

Not about a denied claim?

Nearby states

Sources

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