Last reviewed: 2 October 2026
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When a health insurer denies a claim: what the sources say about internal appeals and external review
The short answer: HealthCare.gov says there are two ways to appeal a health plan decision, an internal appeal to the insurer and an external review by an independent third party, and that a written external-review request must be filed within 4 months after you receive the denial notice or final determination.[1][2] This page reports what the sources say; it is not advice about any particular claim.
This is a summary of what four sources say, not instructions for any particular denial. Which process applies to a given plan, and by what deadline, depends on the plan, the state and the notice the insurer sent.
The two appeal routes
| Route | What the sources say |
|---|---|
| Internal appeal | HealthCare.gov says that if a claim is denied or coverage is canceled you have the right to an internal appeal, asking the insurer for a full and fair review of its decision, and that if the case is urgent the insurer must speed the process up.[1] The statute requires a plan or issuer to have an internal claims appeal process, to notify enrollees of the internal and external processes and of any consumer-assistance office or ombudsman, and to let an enrollee review their file, present evidence and testimony, and receive continued coverage while the appeal is pending.[3] |
| External review | HealthCare.gov describes it as taking the appeal to an independent third party, so that the insurer "no longer gets the final say."[1] It says the external reviewer either upholds the insurer's decision or decides in the consumer's favor, and that the insurer is required by law to accept that decision.[2] |
HealthCare.gov also says insurers have to tell you why they denied a claim or ended coverage, and how you can dispute the decision.[1]
What the external-review page says
- Deadline: a written request must be filed within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied.[2]
- Types of denial listed: any denial involving medical judgment where you or your provider may disagree with the plan; a determination that a treatment is experimental or investigational; and cancellation of coverage based on the insurer's claim that you gave false or incomplete information when you applied.[2]
- Whose process: insurers in all states must offer an external review process meeting federal consumer protection standards. If your state has one that meets or goes beyond them, insurers there follow it; if not, HHS oversees a process, and a plan that does not use a state or HHS process must contract with an independent review organization.[2] The statute likewise points to a state process that includes the protections of the NAIC Uniform External Review Model Act, or to a federal-standards process where the state has none or the plan is self-insured and not subject to state insurance regulation.[3]
- How long it takes: standard external reviews are decided as soon as possible and no later than 45 days after the request was received; expedited reviews no later than 72 hours, or less, depending on medical urgency.[2]
- Cost: no charge in the HHS-administered process; where an issuer uses an independent review organization or a state process you may be charged, and the charge cannot be more than $25 per external review.[2]
- Who can file: you may appoint a representative, such as your doctor or another medical professional who knows about your condition, to file for you.[2]
- Where to find your route: the page says to check your Explanation of Benefits or the plan's final denial of the internal appeal, which gives contact information for the organization that handles external review. For the HHS-administered process it lists a secure website and a toll-free number, 1-888-866-6205.[2]
- Notice on the page: the notice offered a possible extension, ending on October 2, 2026, for some external-review deadlines that fell between July 1 and August 3, 2026 in the HHS-administered process; that date is the last day of the extension, so read the page itself for any newer notice.[2]
What the sources do not give
None of the pages we could read states a filing deadline for the internal appeal. The statute says group plans' internal process incorporates the claims procedures at 29 CFR 2560.503-1 as published on November 21, 2000, updated under Department of Labor standards, and that individual-market issuers follow the applicable law as it stood on March 23, 2010, updated under HHS standards.[3] The regulation page we read lists section 2560.503-1, "Claims procedure," only as a heading,[4] so we do not state its time limits. The denial notice and plan documents are where to look for the internal deadline, and the insurer or a consumer-assistance office can confirm it.
The statute's notes also say that, beginning not later than January 1, 2022, the federal external review process was to apply to adverse determinations under the surprise-billing provisions, including whether an item or service is covered by them.[3] Our surprise medical bills guide covers those provisions.
Who to ask
HealthCare.gov says your state's Consumer Assistance Program or Department of Insurance may be able to help you file an internal appeal or external review, and lists a call line of 1-800-318-2596.[1][2] The statute refers to a state office of health insurance consumer assistance or ombudsman where one exists.[3] The sources do not say which of these is right for any given denial, or what applies to a particular plan; the denial notice is the document they point to.
How to verify this yourself
Open the two HealthCare.gov pages and the statute in the references and compare them with the denial notice you received; where they differ from the notice, ask the insurer or your state regulator which applies. Regulator and federal pages change, so check the dates on the pages you read.
What this page does not cover
It does not cover appeals of Marketplace eligibility decisions, which HealthCare.gov treats as a separate topic;[1] Medicare or Medicaid appeals; or state-specific rules and deadlines. It is general information, not legal, medical or insurance advice, and it does not say whether any claim should have been paid or whether to appeal. For your own situation, ask the insurer, your state's consumer-assistance program or insurance regulator, or a qualified professional.
Related checks
Our standard says how we check an agent's license and disciplinary history, and Check an agent reports our findings at category level. Neither is a review of any insurer, plan or health-care provider, and neither replaces asking the regulator or program named above.
When we will update this page
We re-read the sources when they change. If something here is out of date, tell us; corrections are dated on the page.
References
- [1] HealthCare.gov (CMS), "How to appeal an insurance company decision", read 2 October 2026 — www.healthcare.gov/appeal-insurance-company-decision/
- [2] HealthCare.gov (CMS), "External Review", read 2 October 2026 — www.healthcare.gov/appeal-insurance-company-decision/external-review/
- [3] Legal Information Institute (Cornell), 42 U.S.C. § 300gg-19, Appeals process (unofficial text), read 2 October 2026 — www.law.cornell.edu/uscode/text/42/300gg-19
- [4] Legal Information Institute (Cornell), 29 CFR Part 2560, table of contents (unofficial text), read 2 October 2026 — www.law.cornell.edu/cfr/text/29/part-2560
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