From primary federal sources
Denied? Your clock is already running.
Appeal deadlines and decision turnarounds by coverage type, from primary federal sources. The deadline is rarely the reason people don't appeal.
Of roughly 85 million in-network denied claims on HealthCare.gov marketplace plans in 2024, consumers appealed 262,982 — under 1%. HealthCare.gov marketplace plans only. Appeal rates for employer and Medicare plans are not published at comparable granularity, so this figure must not be presented as covering all payers. Verified Aug 8, 2026 ·kff.org
Commercial / employer plans (ACA + ERISA rules)
- Appeal deadline
- 180 days from the denial notice
- Initial decision
- 72 hours urgent · 15 days pre-service (prior authorization) · 30 days post-service
- Appeal decision
- 30 days pre-service · 60 days post-service · urgent as fast as the condition requires (at most 72 hours / 4 business days)
- External review
- Request within 4 months of the final internal denial. Independent reviewer decides in ≤45 days (≤72 hours expedited). The decision is BINDING on the insurer.
Verified Aug 8, 2026 ·healthcare.gov
Medicare Part D
- Appeal deadline
- 65 calendar days from the coverage determination notice (changed from 60 effective Jan 1, 2026 — many guides are stale)
- Initial decision
- 72 hours standard · 24 hours expedited (clock starts when the plan has the prescriber's supporting statement)
- Appeal decision
- Redetermination: 7 days standard · 72 hours expedited · 14 days payment
- External review
- Five levels: plan redetermination → Independent Review Entity → ALJ hearing (2026 amount-in-controversy ≥ $200) → Medicare Appeals Council → federal court (≥ $1,960).
Verified Aug 8, 2026 ·cms.gov
Medicaid
- Appeal deadline
- Managed care: 60 days from the adverse benefit determination to appeal with the MCO. Fee-for-service fair hearing: state-set, up to 90 days.
- Initial decision
- MCO resolves appeals in ≤30 days standard · ≤72 hours expedited
- Appeal decision
- State fair hearing: final administrative action within 90 days of request; expedited within 3 working days
- External review
- MCO members must exhaust the plan appeal first, then may request a state fair hearing up to 120 days after the appeal-resolution notice (42 CFR 438.408).
Verified Aug 8, 2026 ·macpac.gov
The clock starts on the date printed on your notice
Not the day you opened it, and not the day you called. Find that date, count from it, and work backwards from the deadline for your coverage type above.
The dates above come from each system's own rules, and every card links the document they came from.
Under ERISA you may appoint anyone — a spouse, a friend — as your authorized representative for an appeal (29 C.F.R. §2560.503-1). You do not need a lawyer to appeal, and appeals of GLP-1 denials frequently succeed when the plan's own published criteria are met and documented.