The rules for appealing a denial depend on what kind of plan you have, and using the wrong process can cost you time and rights. An ACA marketplace plan, an employer plan, Medicare, and Medicaid each run on a different track with different deadlines and a different external-review path. This guide helps you identify your plan type and points you to the right route. As always, the process described on your own denial letter and plan documents controls.
ACA marketplace / individual plans
If you bought coverage on the marketplace (or another ACA-compliant individual plan), you generally get a two-stage process: an internal appeal to the insurer (generally within 180 days of the denial), then an external review by an independent organization (generally requested within 4 months of the final internal denial). External review may be run by your state Department of Insurance (DOI) or, where the state does not run one, by a federal HHS-administered independent review organization (IRO).
Employer plans: fully-insured vs self-funded (ERISA)
Most job-based coverage falls under ERISA, but the appeal mechanics split two ways:
- Fully-insured employer plans (the employer buys insurance from a carrier) generally follow the carrier’s state-regulated process, including state external review — similar to ACA plans.
- Self-funded employer plans (the employer pays claims itself, often with a third-party administrator) are governed by ERISA’s “full and fair review” rules under 29 CFR 2560.503-1. You can request the claim file and plan documents free of charge, and oversight runs through the U.S. Department of Labor (DOL/EBSA) rather than a state DOI. Many self-funded plans voluntarily offer a federal external review through an IRO.
Not sure which you have? Your Summary Plan Description or HR benefits office can tell you whether the plan is self-funded. See /guides/request-claim-file-erisa/.
Medicare Advantage vs Original Medicare
- Medicare Advantage (Part C) generally follows: organization determination, then plan reconsideration (file generally within 60 days), then an independent review entity (IRE), then an Administrative Law Judge (ALJ), the Medicare Appeals Council, and finally federal court.
- Original Medicare generally follows: redetermination, then reconsideration, then higher levels similar to the above.
These are distinct from ACA and ERISA tracks, so do not assume the 180-day rule applies — confirm on your Medicare notice.
Medicaid / CHIP
Medicaid and CHIP appeals run through a state fair hearing. Deadlines vary by state — you often must request the hearing within about 90 days, and if you act quickly you can sometimes keep benefits in place while the appeal is pending. Check your state Medicaid notice for the exact window and the continued-benefits rule.
Short-term / limited plans
Short-term and limited-benefit plans are not ACA-compliant and generally carry fewer appeal protections. Read the policy’s own appeal section closely, and check whether your state offers any external review for these plans.
How to tell which plan you have
- Insurance card: names the carrier and sometimes the plan type or network.
- Summary of Benefits and Coverage (SBC): describes coverage and often points to the appeal process.
- Employer HR / plan documents: the Summary Plan Description reveals whether an employer plan is self-funded (ERISA) or fully-insured.
- The denial letter itself: usually names the applicable external-review path — state DOI, a federal IRO, DOL/EBSA, the Medicare IRE, or a state fair hearing.
Notes. ACA-compliant plans generally allow 180 days to file an internal appeal and 4 months to request external review; self-funded employer plans fall under ERISA’s “full and fair review” rules (29 CFR 2560.503-1) with DOL/EBSA oversight, while Medicare and Medicaid use their own multi-stage tracks — the process on your own denial letter controls. To decode your letter see /guides/read-your-denial-letter/, for timeframes see /guides/appeal-deadlines/, and to escalate see /guides/external-review-request/ or /guides/state-doi-complaint/. This is general information, not legal, medical, or insurance advice.