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Know your rights

How appealing a health insurance denial works

Every job-based, Marketplace, and individual plan in the United States has to follow the same federal appeal rules. Some states add more. This page is the map; Overturn applies it to your document.

From the rules dataset, not AIEverything below comes from the same rules dataset the app uses.

The path, in four stages

  1. Stage 1: Read the notice

    A denial has to say why, cite the plan provision, and explain how to appeal. Missing pieces are themselves a problem for the plan.

    • The denial letter itself must meet minimum standards

      A denial notice must state the specific reason, cite the plan provision relied on, describe any extra information needed and why, explain the appeal steps, and either quote the internal criterion used or say you can get it free on request. A letter that skips these can be challenged.

      29 CFR 2560.503-1(g)(1); 45 CFR 147.136(b)(2)(ii)(E)Source (opens in a new tab)Verified Sep 18, 2026

    • You can get your entire claim file for free

      You have the right to receive, free of charge, copies of every document, record, and piece of information the plan used or relied on for your claim, including any internal rule, guideline, or protocol it applied.

      29 CFR 2560.503-1(h)(2)(iii), (g)(1)(v); 45 CFR 147.136(b)(2)(ii)(C)(1)Source (opens in a new tab)Verified Sep 18, 2026

  2. Stage 2: Internal appeal: ask the plan to look again

    You write to the plan. A different, qualified reviewer must decide, within fixed time limits. Most reversals happen here.

    • You have at least 180 days to file an internal appeal

      Federal rules require your plan to give you at least 180 days after you receive the denial to ask the plan to reconsider (an internal appeal). Plans can give more time, never less.

      29 CFR 2560.503-1(h)(3)(i); 45 CFR 147.136(b)(2)(i), (b)(3)(i)Source (opens in a new tab)Verified Sep 18, 2026

    • The plan must decide your appeal within set time limits

      Once you appeal, the plan must answer: within 72 hours if the care is urgent; within 30 days for care you have not received yet (pre-service); within 60 days for care you already received (post-service). Plans with two appeal levels get 15 or 30 days per level.

      29 CFR 2560.503-1(i)(2); 45 CFR 147.136(b)(2)(ii)(B)Source (opens in a new tab)Verified Sep 18, 2026

    • A different, qualified person must review your appeal

      The appeal must be decided by someone who did not make the original decision and who does not report to that person, with no deference to the first decision. For medical-judgment questions, the plan must consult a health professional with appropriate training and experience.

      29 CFR 2560.503-1(h)(3)(ii)-(iii)Source (opens in a new tab)Verified Sep 18, 2026

    • Urgent situations get a 72-hour fast track

      If waiting would seriously jeopardize your life, health, or ability to regain function, or cause severe pain, you can ask for an expedited internal appeal (decided within 72 hours) and, at the same time, an expedited external review.

      45 CFR 147.136(b)(2)(ii)(B), (d)(3)Source (opens in a new tab)Verified Sep 18, 2026

  3. Stage 3: External review: an independent decision

    If the plan says no again, an outside reviewer the plan does not control decides, and the plan must follow the result.

    • You have 4 months to request an independent external review

      After the plan's final internal denial, you can ask for a review by an independent organization that the plan does not control. The request must be made within four months of receiving the final denial. The plan must follow the outcome.

      45 CFR 147.136(d)(2)(i)Source (opens in a new tab)Verified Sep 18, 2026

    • The independent reviewer must decide within 45 days, or 72 hours if urgent

      A standard external review decision is due within 45 days of the reviewer receiving the request. If your situation is urgent, an expedited external review must be decided as fast as your condition requires and never later than 72 hours.

      45 CFR 147.136(d)(2)(iii)(B)(6), (d)(3)(iv)Source (opens in a new tab)Verified Sep 18, 2026

    • If the plan breaks its own procedure, you may skip ahead

      When a plan fails to follow the required claims procedure (for example, misses its deadlines), you are generally treated as having finished the internal appeal, which opens the door to external review or court sooner. Minor, harmless slips do not count.

      29 CFR 2560.503-1(l); 45 CFR 147.136(b)(2)(ii)(F)Source (opens in a new tab)Verified Sep 18, 2026

  4. Stage 4: Surprise bills have their own protection

    Emergency care and out-of-network doctors at in-network hospitals are covered by the No Surprises Act, whatever the plan first decided.

    • Emergency care: no surprise bills, in-network cost sharing, no prior authorization

      For emergency services, the No Surprises Act says your plan must cover the care without prior authorization even if the hospital or doctor was out of network, your share of the cost cannot be higher than the in-network amount, and the provider cannot bill you for the difference.

      45 CFR 149.110(b)(1), (b)(3)(ii); 45 CFR 149.410(a)Source (opens in a new tab)Verified Sep 18, 2026

    • Out-of-network doctor at an in-network hospital: in-network cost sharing applies

      If you had non-emergency care at an in-network hospital or facility but a doctor there was out of network, your cost sharing is limited to the in-network level and that doctor cannot bill you the difference, unless you signed a valid advance notice-and-consent form.

      45 CFR 149.120(c)(1); 45 CFR 149.420(a)Source (opens in a new tab)Verified Sep 18, 2026

    • Some specialties can never make you waive the protection

      Providers of emergency medicine, anesthesiology, pathology, radiology, neonatology, diagnostic services, and assistant surgeons, hospitalists, and intensivists cannot use a consent form to bill you out-of-network rates at an in-network facility. Neither can a provider when no in-network alternative was available or the need was unforeseen and urgent.

      45 CFR 149.420(b)Source (opens in a new tab)Verified Sep 18, 2026

What your state adds

State rules apply to plans regulated by the state (insured job-based plans, Marketplace and individual plans). Overturn currently includes three states; everywhere else, the federal rules above still apply.

California

Two regulators (DMHC and CDI). Independent Medical Review is free and available within six months of the plan's grievance decision.

6 state rules and 2 places to get free help

  • California: 6 months to apply for Independent Medical Review

    If your plan denied, delayed, or modified care as not medically necessary, you can ask the Department of Managed Health Care for an Independent Medical Review (IMR). Apply within six months of the plan's written grievance decision; the department may accept later applications when circumstances warrant. The plan must follow the IMR decision.

    Cal. Health & Safety Code § 1374.30(j), (k)Source (opens in a new tab)Verified Sep 18, 2026

  • California IMR is free

    You pay no application or processing fee of any kind for an Independent Medical Review.

    Cal. Health & Safety Code § 1374.30(l)Source (opens in a new tab)Verified Sep 18, 2026

  • California: file a grievance with the plan first, then the DMHC after 30 days (or right away if urgent)

    You generally start by filing a grievance (appeal) with your plan. If the plan does not resolve it within 30 days, or you disagree with the answer, you can take it to the Department of Managed Health Care. If the situation is an imminent and serious threat to your health, you can go to the department immediately.

    Cal. Health & Safety Code § 1368(b)(1)(A)Source (opens in a new tab)Verified Sep 18, 2026

  • California plans must explain the criteria and clinical reasons in writing

    A plan's written response to a grievance must give a clear and concise explanation of its reasons, and for medical-necessity denials it must describe the criteria used and the clinical reasons for the decision.

    Cal. Health & Safety Code § 1368(a)(5)Source (opens in a new tab)Verified Sep 18, 2026

  • California IMR decisions usually take up to 30 days, or 7 days if urgent

    According to the Department of Managed Health Care, the independent review organization usually decides within 30 days, or within 7 days when the case is urgent.

    DMHC Independent Medical Review program; Cal. Health & Safety Code § 1374.33Source (opens in a new tab)Verified Sep 18, 2026

  • California has two health insurance regulators; check your card

    Most California health plans (all HMOs and many PPOs) are regulated by the Department of Managed Health Care (DMHC). Some PPO and other insurance policies are regulated by the California Department of Insurance (CDI), which runs its own independent medical review. Your insurance card or plan documents say which one applies.

    Cal. Health & Safety Code § 1374.30 (DMHC); Cal. Ins. Code § 10169 (CDI)Source (opens in a new tab)Verified Sep 18, 2026

  • DMHC Help CenterCalifornia's regulator for most health plans. Helps with grievances, Independent Medical Review applications, and complaints. Free.1-888-466-2219Site
  • California Department of Insurance consumer hotlineRegulator for California insurance policies not covered by the DMHC (some PPOs). Handles complaints and its own independent medical review.1-800-927-4357Site

New York

External appeal through the Department of Financial Services within four months; a plan that misses its own appeal deadline is treated as having reversed the denial.

5 state rules and 2 places to get free help

  • New York: 4 months to file an external appeal with DFS

    After your plan's final denial on internal appeal, you can file a New York State External Appeal with the Department of Financial Services. The application must be sent within 4 months of the final adverse determination. An outside doctor decides, and the plan must follow the decision.

    N.Y. Ins. Law § 4914; DFS External Appeal programSource (opens in a new tab)Verified Sep 18, 2026

  • New York external appeal covers more than medical necessity

    New York's external appeal can review denials for medical necessity, experimental or investigational treatment, out-of-network services, clinical trials, rare diseases, and formulary (drug) exceptions, as well as certain No Surprises Act disputes.

    N.Y. Ins. Law § 4910; DFS External Appeal programSource (opens in a new tab)Verified Sep 18, 2026

  • New York external appeal may cost up to $25, refunded if you win

    A plan may charge up to $25 per external appeal (no more than $75 per plan year). The fee is waived for hardship and for Medicaid or Child Health Plus members, and it is returned if the denial is overturned.

    N.Y. Ins. Law § 4914(b); DFS External Appeal programSource (opens in a new tab)Verified Sep 18, 2026

  • New York external appeal is decided in 30 days, or 72 hours if expedited

    Standard external appeals are decided within 30 days. Expedited appeals are decided within 72 hours. You may ask for an expedited internal appeal and an expedited external appeal at the same time.

    N.Y. Ins. Law § 4914(b); DFS External Appeal programSource (opens in a new tab)Verified Sep 18, 2026

  • New York: if the plan misses its appeal deadline, the denial is reversed

    Under New York law, a utilization review agent that fails to decide your appeal within the required time (30 days for a standard appeal after receiving the necessary information; 2 business days for an expedited appeal) is deemed to have reversed its denial.

    N.Y. Ins. Law § 4904(b), (c), (e)Source (opens in a new tab)Verified Sep 18, 2026

  • Community Health AdvocatesNew York's free Consumer Assistance Program. Advocates help you understand denials, file internal and external appeals, and deal with medical bills.1-888-614-5400Site
  • New York Department of Financial ServicesNew York's insurance regulator. Runs the External Appeal program and takes complaints about health plans.1-800-400-8882Site

Texas

Independent Review Organizations certified by the Texas Department of Insurance, paid for by the plan, with a 20-day decision (3 days if life-threatening).

5 state rules and 1 place to get free help

  • Texas: the plan must decide your appeal within 30 calendar days

    A Texas utilization review agent must send written notice of its appeal decision as soon as practicable and no later than the 30th calendar day after it receives your appeal.

    Tex. Ins. Code § 4201.359(a)Source (opens in a new tab)Verified Sep 18, 2026

  • Texas: a denied appeal must state the clinical basis and the reviewer's specialty

    If your appeal is denied, the written notice must include the clinical basis for the denial, the specialty of the provider who made the decision, and your right to seek review by an independent review organization along with the procedure to get it.

    Tex. Ins. Code § 4201.359(b)Source (opens in a new tab)Verified Sep 18, 2026

  • Texas: medical-necessity and experimental denials can go to an Independent Review Organization

    If the plan denies your appeal because the care is not medically necessary or appropriate, or is experimental or investigational, you can ask for review by a TDI-certified Independent Review Organization (IRO) using form LHL009, sent to the plan or its review agent. If your condition is life-threatening, you can request IRO review right after the first denial without waiting for the internal appeal.

    Tex. Ins. Code ch. 4201, subch. I; 28 Tex. Admin. Code § 19.1717; TDI IRO FAQSource (opens in a new tab)Verified Sep 18, 2026

  • Texas IRO review is paid by the insurer and decided in 20 days, or 3 days if life-threatening

    The plan or its review agent pays for the independent review. The IRO decides within 20 days for standard cases and within 3 days for life-threatening cases.

    28 Tex. Admin. Code § 19.1717; TDI IRO FAQSource (opens in a new tab)Verified Sep 18, 2026

  • Texas: TDI helps with plans that show "TDI" or "DOI" on the card

    The Texas Department of Insurance regulates plans whose insurance card shows "TDI" or "DOI". It does not regulate Medicare, Medicaid, most CHIP plans, military plans, or city, county, state, federal employee, and teacher plans; those have their own appeal routes.

    Texas Department of Insurance consumer guidanceSource (opens in a new tab)Verified Sep 18, 2026

  • Texas Department of Insurance Consumer Help LineTexas's insurance regulator. Explains appeals and independent review, and takes complaints about plans it regulates.1-800-252-3439Site

Not in one of these states? Every state has an insurance department and most have a free Consumer Assistance Program: find yours on CMS.gov.

Common questions

What is an Explanation of Benefits (EOB)?

A statement from your plan showing what a provider charged, what the plan allowed and paid, and what you may owe. It is not a bill, but it is often the first place a denial shows up, as a remark code next to a line item.

How long do I have to appeal?

Under federal rules, at least 180 days from the day you receive the denial to file an internal appeal, and four months after the plan's final internal decision to request external review. Plans can give more time, never less. State rules can add options on top.

What is a self-funded plan, and why does it matter?

Many large employers pay claims from their own money and hire an insurer only to administer the plan. Those plans follow federal rules only; state external-review laws generally do not reach them. Your Summary Plan Description or HR can tell you. If you are not sure, Overturn shows both routes.

Did I already miss my deadline?

Count from the day you received the notice, not the day it was written. If the window has closed, plans sometimes accept late appeals for good cause, and a complaint to the regulator remains possible. The free help services listed below can tell you what is still open.

Do I need a lawyer?

Most internal appeals and external reviews are filed by patients themselves or with a free consumer assistance program. Overturn provides information to help you do that; it does not give legal advice and cannot tell you what to do in your specific case. If you want advice, a lawyer or your state's consumer assistance program is the place to get it.

Does Overturn cover Medicare or Medicaid?

No. Those programs have their own multi-level appeal systems with different deadlines. Overturn recognizes those documents and stops with a link to the official process rather than applying the wrong rules.

What happens to my document?

It is read once, in memory, during a single request, and discarded. Nothing is stored on a server; your session lives in your browser tab. The sample documents are fictional.

Have a denial in hand?

Overturn applies all of this to your document in about a minute.

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