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

In Wisconsin, your health plan is regulated by Wisconsin Office of the Commissioner of Insurance (OCI), if it is a state-regulated plan.

Wisconsin 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.

Wisconsin Medicaid and BadgerCare Plus

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

Marketplace (HealthCare.gov) 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 Wisconsin?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months (federal rule) — The date the insurer's grievance decision was provided to you (the date on the grievance resolution letter)
Hearing deadline
45 days — The effective date of the action (DHA must receive your request within 45 days)
Keeping your benefits during the appeal
If DHA receives your hearing request before the agency's action takes effect, your Medicaid will not stop or be reduced while the hearing is pending. Tell DHA in your request if you do not want benefits to continue.
Appeal to the plan first
60 days (federal rule)
Then a state hearing
90 days
Appeal deadline – HealthCare.gov
90 days (federal rule)

How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

If your plan is self-funded by your employer, it is subject to federal, not state law; contact the U.S. Department of Labor (1-866-444-3272). Medicare and Medicaid have their own appeal processes.

Law: OCI, Health Insurance Grievances and Complaints (PI-217)

Step 1: Appeal to your plan in Wisconsin

What it is called: Grievance

Time to file

Wisconsin guidance does not give a longer deadline. Use the deadline on your denial notice; federal rules give at least 180 days for most plans.

How fast the plan must decide

Standard: 30 days

Send your grievance in writing to the address on your denial notice. Your plan must acknowledge it within 5 business days. You may attend the grievance panel meeting in person or by phone; the plan must tell you the time and place at least 7 days ahead. The plan should send its decision within 30 days of receiving your grievance, or up to 30 days more if it sends you a written notice explaining why. You can ask for an expedited grievance if waiting would seriously jeopardize your life or health or your ability to regain maximum function, or if your doctor asks for it.

Law: OCI, Health Insurance Grievances and Complaints (PI-217); Wis. Stat. 632.83

Step 2: Outside review in Wisconsin

Program

Independent Review

Who runs it
  • HHS-administered federal external review (Maximus Federal Services) or an independent review organization (IRO) contracted under the federal Department of Labor process: Most insured health plans in Wisconsin
  • Independent review organizations certified by OCI (Wisconsin independent review): Plans subject only to Wisconsin's independent review law
Deadline to ask

Federal rule: at least 4 months.

OCI says to send your request within four months (120 days) of the date the grievance decision was provided to you, to the address in the insurer's final written decision. Under Wisconsin's own independent review process (used only by some plans), the IRO decides within 30 business days after it has all the information it needs, or within 72 hours if waiting could jeopardize your life or health.

The deadline runs from

The date the insurer's grievance decision was provided to you (the date on the grievance resolution letter)

Do I have to appeal to my plan first?

Generally you must finish the insurer's grievance process first. You can skip it if you and the insurer agree, or if you need immediate care: send your expedited review request to the IRO at the same time as your expedited grievance, and the IRO decides whether an immediate review is needed.

Cost

OCI says Wisconsin's own independent review process costs you nothing and the insurer pays the reviewer. Under the federal process, which most Wisconsin plans use, a fee of up to $25 may apply.

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

Denials because the insurer says a covered treatment is not medically necessary or is experimental (including out-of-network care when you believe the provider's expertise is medically necessary), preexisting condition exclusions, and retroactive cancellation of your policy (rescission). Not eligible: services that are not a covered benefit, administrative issues such as late premiums, and Medicare, Medicaid, other federal plans and employer self-funded plans. For plans subject only to Wisconsin's law, the dispute must also involve a minimum dollar amount that is adjusted each year ($403 for 2023).

Is the decision final?

The IRO's decision is binding on both you and the insurance company.

How to ask

Send a written request to the address in the insurer's final grievance decision. Include your name, address and phone number, why you believe the treatment should be covered, copies of supporting records (for example medical records, test results, a letter from your doctor), a signed statement if someone else files for you, and anything else the insurer asks for. The insurer sends your file to the IRO within 5 business days.

Law: OCI, Independent Review Process in Wisconsin (PI-203); Wis. Stat. 632.835

Phone

OCI 1-800-236-8517

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 Wisconsin: faster decisions

Outside review

If waiting could jeopardize your life or health, the IRO must tell you and the insurer its decision no later than 72 hours after it receives the request.

Law: OCI, Independent Review Process in Wisconsin (PI-203); Wis. Stat. 632.835

Medicaid

For Medicaid managed care service denials, a hearing request on a denial of an expedited (urgent) appeal must be decided within 3 working days of receipt. DHA also expedites requests from people who plan to move out of Wisconsin before a decision would normally be issued.

Law: Wis. Stat. 49.45(5); BadgerCare Plus Handbook 29.2

Complaints about your plan in Wisconsin

If you cannot resolve a problem with your insurer, or you are not satisfied with how it handled your claim, you can file a complaint with OCI online or call 1-800-236-8517 (608-266-0103 from outside Wisconsin). OCI cannot help with employer self-funded plans.

sbs.naic.org

Medicaid (Wisconsin Medicaid and BadgerCare Plus (ForwardHealth)) denials in Wisconsin

Who holds the hearing: Wisconsin Department of Administration, Division of Hearings and Appeals (DHA).

Hearing deadline: 45 days

All the details →

Marketplace decisions in Wisconsin

Wisconsin uses HealthCare.gov. Appeals go to the federal Marketplace Appeals Center.

HealthCare.gov

1-855-231-1751

How long do I have? Deadline calculator

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

Good to know in Wisconsin

  • HHS lists Wisconsin as a state that uses the federal external review process; OCI says most Wisconsin health plans follow the federal process (OCI, PI-217).
  • Wisconsin's own independent review law applies only to some plans and requires a minimum dollar amount in dispute, adjusted each year (OCI, Independent Review Process Minimum Adjusted Dollar Amount).
  • Wisconsin Medicaid gives 45 days from the effective date of the action to request a fair hearing, shorter than the federal maximum.

    Law: Wis. Stat. 49.45(5)(a); BadgerCare Plus Handbook 29.2.2

Questions about appeals in Wisconsin

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

Wisconsin guidance does not give a longer deadline. 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 Wisconsin?

Send a written request to the address in the insurer's final grievance decision. Include your name, address and phone number, why you believe the treatment should be covered, copies of supporting records (for example medical records, test results, a letter from your doctor), a signed statement if someone else files for you, and anything else the insurer asks for.

Is outside review free in Wisconsin?

OCI says Wisconsin's own independent review process costs you nothing and the insurer pays the reviewer. Under the federal process, which most Wisconsin plans use, a fee of up to $25 may apply.

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

45 days. The effective date of the action (DHA must receive your request within 45 days)

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

If DHA receives your hearing request before the agency's action takes effect, your Medicaid will not stop or be reduced while the hearing is pending. Tell DHA in your request if you do not want benefits to continue.

Who regulates health insurance in Wisconsin?

Wisconsin Office of the Commissioner of Insurance (OCI). If your plan is self-funded by your employer, it is subject to federal, not state law; contact the U.S. Department of Labor (1-866-444-3272). Medicare and Medicaid have their own appeal processes.

Not about a denied claim?

Nearby states

Sources

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