Appeals process & timelines

The end-to-end playbook for fighting a health-insurance denial in the United States — what the categories mean, what evidence you need, how the timeline works, and when to bring in help.

After a denial you generally have two layers of appeal. Internal appeal is the insurer reviewing its own decision; external review is an independent organization. Here's how they differ and when each applies.

Federal deadlines insurers must hit on internal appeals (30/60/72), the week-by-week calendar of a standard post-service appeal, expedited 72-hour rule, and the second 60-day external-review clock.

Options after missing the 180-day federal floor — calculating how late you are, good-cause exceptions, procedural defects in the original notice, state insurance department complaints, and the narrow paths to external review without internal exhaustion.

The 72-hour expedited internal appeal — clinical situations that qualify (ongoing inpatient, scheduled surgery, urgent medication, end-of-life), how to phrase the written request, and how to file expedited external review in parallel.

What goes on inside the insurer after you file — acknowledgment timing, the claims rep → nurse → medical director → peer review pipeline, what reviewers actually look at, common stalls, follow-up strategy, and what to do when the clock runs out.

Decision tree after an internal denial — when external review is your strongest move (medical necessity, experimental, clinical-judgment prior auth), when it isn't (clear plan exclusions, eligibility, pure billing), state vs federal external review systems, and when to stop appealing.

Walks through Aetna's publicly-published Clinical Policy Bulletins, internal utilization-review flow (nurse → medical director), denial-letter language to decode, and the IRO external review path.

Decodes UHC's appeal levels, the role of Optum/OptumRx/Optum Behavioral Health in clinical review, the peer-to-peer-review option, and Provider Portal vs member appeals path.

Explains Cigna's centralized appeals unit, Evernorth/Express Scripts/Accredo involvement on pharmacy denials, and how to dismantle a medical-necessity denial by quoting Cigna's own SPD definition.

Untangles BCBS as a 33-member federation; how to identify your specific plan from the EOB header and ID alpha prefix; BlueCard out-of-state routing; when to escalate to state DOI.

Covers why Kaiser's integrated payer-provider model makes internal appeals structurally limited and positions California's DMHC Independent Medical Review (IMR) as the strongest external path.

ERISA governs most employer health plans: 29 CFR 2560.503-1 timelines, 'full and fair review,' self-funded vs fully-insured distinction, HHS federal external review path, and the practical implications for the appeal letter.

The 45 CFR 147.136 floor — 180 days to file, 30/60/72-hour decision windows, full and fair review, binding external review — and which plans (grandfathered, short-term, fixed-indemnity) it does not reach.