How to appeal a denied health insurance claim in Connecticut
In Connecticut, with most private health plans, you have 180 days from getting the denial notice to file an internal appeal, and urgent cases must be decided within 72 hours. If the plan still says no, you can ask for an independent external review within 4 months, and the plan must follow the reviewer's decision. For free help, contact the Connecticut Insurance Department.
Free help in Connecticut
Connecticut Insurance Department
Connecticut's Office of the Healthcare Advocate also helps with appeals for free: portal.ct.gov/oha.
Medicaid: Connecticut Medicaid agency and contacts
Private health plans in Connecticut: internal appeal and external review
Your plan must review its decision, and if it still says no, an independent reviewer can decide instead.
- 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.
| 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 |
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.
Which kind of plan do you have?
| Marketplace or individual plan (HealthCare.gov, state exchange or bought directly) | These plans are regulated by your state, so your state insurance department oversees appeals and external review. |
|---|---|
| Job-based plan bought from an insurer (fully insured) | Your employer bought this plan from an insurer, so your state insurance department regulates the insurer and oversees external review. |
| Job-based plan your employer pays for itself (self-funded, ERISA) | 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. |
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.
Where to get free help in Connecticut
- Connecticut Insurance Department: https://portal.ct.gov/cid
- HealthCare.gov local help: https://www.healthcare.gov/find-local-help/ or 1-800-318-2596.
- Free consumer help with appeals, state by state: https://www.healthcare.gov/how-can-i-get-consumer-help-if-i-have-insurance/
- 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.
Medicaid and CHIP in Connecticut
With Medicaid in Connecticut, you have the right to a state fair hearing. If you are in a Medicaid plan, appeal to the plan first within 60 days of the notice, and to keep a current service going, ask within 10 days. Your state Medicaid agency or local legal aid can help for free.
- If you are in a Medicaid managed care plan, appeal to the plan first within 60 days of the date on the notice. The plan decides within 30 days, or 72 hours if urgent.
- If the plan still says no, ask for a state fair hearing. States give between 90 and 120 days from the plan's decision.
- If you are not in a managed care plan, ask the state for a fair hearing directly. States allow up to 90 days from the date the notice was mailed, and some allow less, so check your notice.
- To keep a current service going during the appeal, ask within 10 days of the notice, or before the change takes effect, whichever is later.
| Step | File within | Decision due |
|---|---|---|
| Managed care plan appeal | 60 days from the date on the notice | 30 days, or 72 hours if urgent |
| State fair hearing after a plan appeal | 90 to 120 days from the plan's decision, set by your state | |
| State fair hearing without a plan | up to 90 days from the date the notice was mailed, set by your state | |
| Keep services during the appeal | 10 days from the notice, or before the change takes effect, whichever is later |
Free help:
- Connecticut Medicaid agency and contacts: https://www.medicaid.gov/state-overviews/stateprofile.html?state=connecticut
- Free legal aid near you: https://www.lawhelp.org/
Medicare in Connecticut
- Original Medicare: With Original Medicare in Connecticut, start by asking for a redetermination by the date on your Medicare Summary Notice, generally 120 days from when you get it. There are five appeal levels in all, and each decision letter explains the next step. Your State Health Insurance Assistance Program gives free one-to-one help.
- Medicare Advantage: With a Medicare Advantage plan in Connecticut, ask the plan to reconsider within 65 days of the date on the denial notice, and ask for a fast appeal if waiting could harm your health. If it still says no, your case goes to an independent reviewer automatically. Your State Health Insurance Assistance Program gives free one-to-one help.
- Part D drug plans: With a Medicare drug plan in Connecticut, ask the plan to reconsider within 65 days of the date on the denial notice, and ask for a fast appeal if waiting could harm your health. If it still says no, you can ask an Independent Review Entity within 60 days. Your State Health Insurance Assistance Program gives free one-to-one help.
Free help:
- 1-800-MEDICARE (1-800-633-4227).
- Your State Health Insurance Assistance Program (SHIP) gives free, one-to-one Medicare help: https://www.shiphelp.org/
Quick answers
- How long do I have to appeal a health insurance denial in Connecticut?
- 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. Check the date on your own notice.
- Who can help me appeal for free in Connecticut?
- Connecticut Insurance Department: https://portal.ct.gov/cid Connecticut's Office of the Healthcare Advocate also helps with appeals for free: portal.ct.gov/oha.
- How do I appeal a Medicaid denial in Connecticut?
- With Medicaid in Connecticut, you have the right to a state fair hearing. If you are in a Medicaid plan, appeal to the plan first within 60 days of the notice, and to keep a current service going, ask within 10 days. Your state Medicaid agency or local legal aid can help for free.
- How do I appeal a Medicare denial in Connecticut?
- With Original Medicare in Connecticut, start by asking for a redetermination by the date on your Medicare Summary Notice, generally 120 days from when you get it. There are five appeal levels in all, and each decision letter explains the next step. Your State Health Insurance Assistance Program gives free one-to-one help.
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://portal.ct.gov/cid
- https://www.medicaid.gov/state-overviews/stateprofile.html?state=connecticut
- https://www.healthcare.gov/appeal-insurance-company-decision/
- https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
- https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
- 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.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip
- https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F
- https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-431/subpart-E/section-431.221
- https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals
- https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/original-medicare
- https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS20027.pdf
- https://www.federalregister.gov/documents/2025/12/04/2025-21879/medicare-program-medicare-appeals-adjustment-to-the-amount-in-controversy-threshold-amounts-for
- https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans
- https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/drug-plans
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