ERISA appeals: when federal law governs your plan

The first question: is your plan ERISA?

ERISA covers most private-sector employer health plans. It does not cover:

• Plans you buy yourself on the individual market (including most ACA Marketplace plans).
• Medicare and Medicaid.
• Government employee plans (federal, state, municipal).
• Most church plans (though some elect into ERISA).

If you got your coverage through your job at a private company, assume ERISA applies until you confirm otherwise. The Summary Plan Description (SPD) you can request from your HR or benefits office will usually state whether the plan is governed by ERISA.

Self-funded vs fully-insured — and why it matters

Within ERISA there is a second split that drives a lot of practical outcomes.

• Fully-insured ERISA plan. The employer pays premiums to an insurance company, which bears the risk and pays claims. State insurance laws still apply to the insurer alongside ERISA. State external-review programs apply.
• Self-funded ERISA plan. The employer pays claims directly out of its assets and contracts a third-party administrator (often a familiar insurance brand operating as an Administrative Services Only or ASO carrier). State insurance laws are preempted. Many state mandates (fertility coverage, autism mandates, parity surcharges) do not apply. External review is administered federally through HHS via a certified Independent Review Organization.

The denial letter will sometimes say “administered by” or “claims paid by employer” — that is usually the self-funded signal. If you see a brand like Aetna, Cigna, or UnitedHealthcare on the letter but the employer’s name on the Plan documents, ASO is very likely. Check the SPD; it will tell you the plan sponsor and the funding arrangement.

“The familiar logo on the denial letter is often the third-party administrator, not the entity actually paying claims. On a self-funded plan, that distinction changes which laws apply.”

The federal claims-procedure rules — 29 CFR 2560.503-1

For health-insurance appeals under ERISA, the operative regulation is 29 CFR 2560.503-1. In broad strokes, it generally requires plans to:

1. Decide initial pre-service claims within 15 days (one 15-day extension permitted for circumstances beyond the plan’s control), and post-service claims within 30 days (one 15-day extension permitted).
2. Decide internal appeals within 30 days for pre-service claims and 60 days for post-service claims. Urgent-care claims must be decided within 72 hours both at the initial and appeal stages.
3. Conduct a “full and fair review.” The reviewer cannot be the same person (or a subordinate) who made the initial denial. The reviewer must have appropriate expertise where a medical judgment is involved. The plan cannot rely on new evidence on appeal without giving you a chance to respond.
4. Provide your full claim file on request, free of charge. This includes the internal medical-review notes, the guidelines used, the names and credentials of reviewers, and the relevant plan-language excerpts.
5. Explain the specific reasons for denial, identify the plan provisions relied on, and describe what additional information could change the result.

What “full and fair review” means in practice

The phrase appears in the regulation and shows up in nearly every consumer-facing ERISA decision. In practice it covers a set of procedural rights you can rely on in the appeal letter:

• You are entitled to all documents the plan considered, including internal clinical guidelines, criteria, and reviewer reports.
• The plan cannot quietly introduce new medical evidence at the appeal stage without sharing it and giving you a meaningful opportunity to respond before the decision.
• For medical-judgment denials, the reviewer must consult a health-care professional with appropriate training and experience in the relevant field.
• The decision letter must identify the specific plan provisions and the specific clinical reasons.

When an internal appeal is decided with a one-line generic denial that does not engage with the evidence, that is itself a procedural problem you can flag in the next step.

How ERISA differs from an ACA Marketplace appeal

The structural protections are similar — both regimes guarantee internal appeal and external review — but a few important differences come up:

• Source of timelines. ERISA plans follow 29 CFR 2560.503-1. ACA Marketplace plans follow the ACA regulations at 45 CFR Part 147, which closely mirror the ERISA rules. See the ACA appeal rights guide for the Marketplace-side detail.
• External review path. Self-funded ERISA plans default to a federal HHS-administered external review. Fully-insured ERISA plans usually use the state external-review program. The internal vs external review guide walks through the differences.
• State remedies. ERISA preempts most state-law remedies such as bad-faith claims and consequential damages. Marketplace and individual-plan disputes are subject to state insurance law in addition to the ACA.
• Court. If you ultimately need to litigate an ERISA dispute, the case is in federal court under ERISA Section 502, generally on the administrative record and under a deferential standard of review. State-law breach-of-contract theories are usually preempted.

A practical ERISA-appeal checklist

1. Request your claim file in writing the day you read the denial letter. The plan must produce it free of charge.
2. Calendar the 180-day internal-appeal deadline and any plan-specific shorter deadline.
3. Identify whether the plan is self-funded. The SPD will tell you. This determines the external-review path and any state-law arguments available.
4. Write the appeal to the federal standard. Cite the plan-language provisions, the specific clinical reasoning, and any procedural defects in the initial denial (no specialist review, undisclosed criteria, missed timelines).
5. Preserve the record. Keep every document. ERISA litigation is largely decided on the administrative record assembled during the appeals process.
6. If denied, request external review through the appropriate pathway (HHS federal IRO for self-funded; state IRO for fully-insured). The appeal timeline guide has the full deadline grid.

Where InsureDefense helps

ERISA appeals reward precision: the right plan-language citations, the right regulatory references (29 CFR 2560.503-1(h) for full and fair review, (f) for timelines), and a clean record. Our Premium tier prepares ERISA-structured appeals that engage with the plan’s own criteria, attach peer-reviewed support, and preserve the record for external review. Start by uploading the denial letter and the Summary of Benefits and Coverage — we can usually tell within minutes whether the plan is self-funded.

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