Appeal guide

Public-employer plan

  1. Send your appeal here

    Public-employer plan

    Government plans don't file Form 5500 and aren't covered by ERISA. Ask HR one question: "Is our medical plan fully insured or self-funded?"

  2. Know your deadlines

    • Internal appeal to the plan or insurer180 days from the denial
    • Independent external review4 months from the final denial

    Dates you enter stay on this device.

  3. What happens next

    1. Internal appeal to the plan or insurer

      File in writing within 180 days of the denial notice. Ask for your complete claim file and the criteria they used. They must give it to you free. They decide within 30 days for care you haven't had yet, 60 days for care you already received.

    2. Independent external review

      If they say no again, request external review within 4 months of that final denial. If the plan is insured, your state runs it. If it is self-funded, it usually goes through the federal HHS-run process, or your state's program if your state covers public plans. A reviewer outside the plan decides, usually within 45 days, and the plan must follow the decision.

    3. Urgent? Ask for an expedited review

      If waiting could seriously harm your health, say so in writing. The plan must decide within 72 hours, and you can ask for expedited external review at the same time.

  4. Get free help

    External review covers denials based on medical judgment ("not medically necessary", "experimental"), cancelled coverage, and surprise-billing disputes. A flat plan exclusion usually isn't eligible, but you can still file the internal appeal.

Coming next

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