How to appeal a self-funded (ERISA) job-based plan denial
You have 180 days from getting the denial notice to file an internal appeal. The plan decides within 30 days for care you haven't had, 60 days for care you've had, or 72 hours if urgent. After a final denial, you have 4 months to ask for an external review.
Who decides
Self-funded job-based plans are covered by federal law (ERISA), so the US Department of Labor, not your state, oversees them. External review is usually run by independent review organizations the plan contracts with, or a federal process.
Steps
- Read the denial notice. It must say why the claim was denied and how to appeal.
- File an internal appeal with your plan within 180 days of getting the notice. Ask your doctor for a letter explaining why the care is needed.
- If the internal appeal is denied, ask for an external review by an independent reviewer within 4 months of that final denial. Your plan must accept the reviewer's decision.
- If your situation is urgent, ask for an expedited appeal. You can ask for an urgent external review at the same time as the internal appeal.
Deadlines
| Step | File within | Decision due |
|---|---|---|
| Internal appeal | 180 days from when you got the denial notice | 30 days for care you have not had yet, 60 days for care you already had, 72 hours if urgent |
| External review | 4 months from the final internal denial | 45 days standard, 72 hours or sooner if urgent |
Dates are a guide. Count from the date on your notice, or the day you received it where the rule says so, and use any date printed on your notice if it differs. File early and keep proof of when you sent it.
If it is urgent
If waiting could seriously harm your health, ask for an expedited (fast) appeal and have your doctor say it is urgent. For private plans you can ask for an urgent external review at the same time.
After the plan's appeals
After the plan's appeals, ERISA gives you the right to go to court to recover benefits due under the plan (ERISA section 502(a)). Plans must give you, free of charge, copies of documents relevant to your claim.
Grandfathered plans (in place since before March 2010 and not changed much) and short-term plans may not have to follow these appeal rules. Your plan documents say if yours is grandfathered.
Where to get free help
- US Department of Labor, EBSA: 1-866-444-3272 or https://www.dol.gov/agencies/ebsa. Benefits advisers there help for free.
- Some states let self-funded plans use the state external review. Your plan documents say which process applies.
- Free consumer help with appeals, state by state: https://www.healthcare.gov/how-can-i-get-consumer-help-if-i-have-insurance/
Free help in your state
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Puerto Rico
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
What to send with your appeal
- A copy of the denial notice or Explanation of Benefits.
- A letter from your doctor explaining why the care is needed (a letter of medical necessity).
- Relevant medical records, test results and notes on treatments already tried.
- The pages of your plan documents that support coverage.
- Notes of phone calls: date, time, who you spoke to and what they said.
- Keep copies of everything, send it in a way you can track, and ask the plan to confirm it arrived.
Draft an appeal letter for the reason on your notice: not medically necessary, not an emergency, experimental, out of network, no prior authorization, a coding error or another reason.
Quick answers
- How long do I have to appeal?
- You have 180 days from getting the denial notice to file an internal appeal. The plan decides within 30 days for care you haven't had, 60 days for care you've had, or 72 hours if urgent. After a final denial, you have 4 months to ask for an external review.
- Who decides my appeal?
- Self-funded job-based plans are covered by federal law (ERISA), so the US Department of Labor, not your state, oversees them. External review is usually run by independent review organizations the plan contracts with, or a federal process.
- What if my case is urgent?
- If waiting could seriously harm your health, ask for an expedited (fast) appeal and have your doctor say it is urgent. For private plans you can ask for an urgent external review at the same time.
General information, not legal or medical advice. Rules differ by plan and state, so check the dates and instructions on your own denial notice, and talk to your doctor about the medical side. Free help is available from your state and the contacts listed.
Sources
- https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-health-benefits
- https://www.dol.gov/agencies/ebsa
- https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
- https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
Ask Appeal My Claim yourself
Enter the date on your denial notice and get an approximate file-by date for each step. Open Appeal My Claim, free, no sign-up.
In Claude or any app that takes MCP connectors, add https://goodturn-mcp.pages.dev/appealmyclaim/mcp and ask: “How long do I have to appeal a self-funded job-based plans (erisa) denial?”