Appeal process · Plan types

ERISA appeals: the rules for employer self-funded plans

If your coverage comes through a large employer, it's probably self-funded under ERISA — which means federal claims rules, not state insurance law, govern the appeal. That changes the deadline, the disclosures you can demand, and what happens if the plan still says no.

ERISA governs most employer-sponsored self-funded plans. Its claims-procedure rule gives you at least 180 days to file an internal appeal of an adverse benefit determination, guarantees a “full and fair review,” and entitles you to the documents and criteria the plan relied on. You generally must exhaust internal appeals before suing, and self-funded plans provide external review through the federal process — state external review does not apply.

Self-funded vs. fully insured — why it decides everything

In a self-funded plan the employer bears the claims risk and usually hires an insurer to administer it; the insurance company's name on the card is the claims administrator, not the risk-bearer. Self-funded plans are governed by ERISA and federal rules, and are not subject to state insurance mandates or the state external-review process.

  • Large-employer coverage is frequently self-funded; the plan documents (SPD) will say “self-funded” or “self-insured.”
  • State insurance mandates and the state Department of Insurance generally do not apply to a self-funded plan.
  • The federal claims-procedure rule (29 CFR 2560.503-1) sets the appeal rights and timeframes instead.

Your ERISA appeal rights

  • At least 180 days from the adverse benefit determination to file your internal appeal.
  • A full and fair review by a person who was not involved in (and does not report to whoever made) the original denial.
  • On request and free of charge, the documents, records, and internal criteria the plan relied on.
  • The specific reasons for the denial and the plan provisions it rests on.
  • For a medical-judgment denial, consultation with an independent health professional with appropriate expertise.

The decision clocks

Group health plans must decide an appeal within set windows: generally 30 days for pre-service care, 60 days for post-service claims, and 72 hours for urgent care. Missing them can let you treat internal remedies as exhausted.

Exhaust internal appeals before you sue

ERISA generally requires you to exhaust the plan's internal appeals before filing suit under ERISA §502(a). The flip side is a lever: if the plan fails to follow the claims-procedure rules, the internal remedies may be “deemed exhausted,” opening the courthouse door earlier. Either way, build the administrative record carefully — in many ERISA cases a court reviews what was in front of the plan, not new evidence.

External review for self-funded plans

Non-grandfathered self-funded plans must offer an independent external review after the final internal denial — but through the federal process (an HHS-administered review or a plan-contracted independent review organization), not the state process that fully insured plans use. The standard is a four-month window to request it after the final internal denial.

How to run an ERISA appeal

  1. 1

    Get the plan's basis and documents

    Request, in writing, the specific denial reasons and free copies of the records and internal criteria the plan relied on — your right under the rule.

  2. 2

    File within 180 days, mapped to the criteria

    Submit the internal appeal with the clinical record tied to the plan's own criteria, point by point, well inside the 180-day window.

  3. 3

    Demand a full and fair review

    The reviewer must be independent of the original decision and, for a medical-judgment denial, must consult an appropriately qualified clinician.

  4. 4

    Escalate to federal external review

    After the final internal denial, request the federal external review (HHS-administered or a contracted IRO) within the four-month window.

Frequently asked

How do I know if my plan is ERISA / self-funded?
Check the summary plan description: a self-funded plan says “self-funded” or “self-insured,” and the insurer is listed as the claims administrator rather than the insurer of record. Large-employer coverage is commonly self-funded.
How long do I have to appeal an ERISA denial?
At least 180 days from the adverse benefit determination to file the internal appeal, under the federal claims-procedure rule. Confirm the exact date on your denial notice.
Can I sue my self-funded plan?
Generally only after exhausting the plan's internal appeals, under ERISA §502(a) — unless the plan failed to follow the claims rules, which can let you treat internal remedies as exhausted.

Primary sources: 29 CFR 2560.503-1 (ERISA claims procedure); DOL EBSA — Filing a claim for benefits. General information, not legal or medical advice — confirm against the governing rule for the plan type.

Related guides

External reviewMedical-necessity letterExternal review by state

When the appeal has to be written, and cited

Upload the denied EOB and Merits returns a complete, citation-verified appeal letter — the clinical argument, the payer's own coverage criteria, and your federal appeal rights — in about a minute.

Appeal a denial →