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.
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 31, 2026 · healthcare.gov· healthcare.gov· ecfr.gov
Medicare Part D
Appeal deadline
65 calendar days From the date on the coverage determination notice. If you see 60 days elsewhere, both are right and neither is out of date: the regulation gives you 60 calendar days from RECEIPT of the notice and presumes receipt 5 calendar days after the notice is dated (42 CFR 423.582), which is the 65 CMS publishes. Counting 65 from the date printed on your letter is the safe reading; if you can show the notice reached you later, the 60 days run from the day it actually arrived.
- 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).
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 31, 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.
Specialized Appeal Strategies & Guides
Explore targeted guides for the three most common coverage roadblocks:
Sleep Apnea Route (ICD-10 G47.33)
How to get Zepbound covered when your employer plan specifically excludes weight loss drugs.
Step Therapy Override Guide
The 5 standard exception grounds to bypass "fail-first" rules, and where state decision deadlines apply.
Savings Card Cap Exhaustion
What each card's published annual cap really covers, and how to switch to manufacturer direct pricing when it runs out.