How long do I have to appeal a Medicare denial?

For traditional Medicare (Part A and Part B), the deadline for the first level of appeal — called a redetermination — is 120 days from the date of the initial determination notice, per 42 CFR 405.942(a). For Medicare Advantage (Part C), the deadline is 60 days from the notice of adverse coverage determination, per 42 CFR 422.582(b).

What is the appeal deadline for an ERISA plan?

Under 29 CFR 2560.503-1(h)(3)(i), group health plans subject to ERISA must allow at least 180 days from the date of the adverse benefit determination notice for the claimant to file an internal appeal. This is the same window that applies to ACA-compliant fully-insured commercial plans.

Insurance Appeal Deadlines by Plan Type

The appeal deadline for a denied health insurance claim is determined by the type of plan — federal law, not the payer, sets the minimum. ERISA self-funded employer plans, ACA-compliant commercial plans, traditional Medicare, Medicare Advantage, and Medicaid each operate under a different regulatory framework with a different minimum deadline.

The clock starts at the denial notice, not the date of service. The deadline runs from the date on the adverse benefit determination letter or EOB — the formal document communicating the denial. Start counting from there, not from when care was delivered or the claim was filed.

Deadlines by plan type

ERISA

ERISA self-funded employer plan

Internal appeal

180 days from the adverse benefit determination

External review

Available for non-grandfathered plans under the ACA; varies by state for fully-insured ERISA plans

The most permissive internal deadline of the major plan types. The 180-day window runs from the date on the adverse determination notice — not from the date of service or the date of the original claim. Fully-insured ERISA plans are subject to state-law external review.

29 CFR 2560.503-1(h)(3)(i) ↗

ACA

ACA-compliant commercial plan (non-grandfathered)

Internal appeal

180 days from the adverse benefit determination

External review

4 months from exhaustion of internal appeals (most states follow federal HHS external review process)

Fully-insured plans sold on or off the ACA marketplace. For urgent (concurrent or expedited) care claims, the payer must decide within 72 hours. External review is available through the state process or the federal HHS/MAXIMUS process, depending on the state.

45 CFR 147.136(b)(3) ↗

Medicare FFS

Medicare traditional (Part A and Part B)

Internal appeal

120 days from the date of the initial determination notice

External review

ALJ hearing available if the amount in controversy meets the threshold; Federal District Court after ALJ

Medicare has a five-level appeals process: redetermination (contractor), reconsideration (Qualified Independent Contractor), ALJ hearing, Medicare Appeals Council, and Federal District Court. The 120-day deadline applies to the first level (redetermination). Each subsequent level has its own filing window.

42 CFR 405.942(a) ↗

Medicare Advantage

Medicare Advantage (Part C)

Internal appeal

60 days from the notice of adverse coverage determination

External review

Independent review entity (IRE) after plan-level appeal

MA plans have tighter deadlines than traditional Medicare. The plan must acknowledge an appeal within 60 days of a standard (non-urgent) request. Expedited appeals for urgent care must receive a decision within 72 hours. After an unfavorable MA plan decision, the case goes to an IRE.

42 CFR 422.582(b) ↗

Medicaid

Internal appeal

At least 90 days from the notice of action (federal floor); many states set longer windows

External review

Varies by state; federal fair-hearing process available

The 90-day window is the federal minimum — individual states may extend it. The right to a fair hearing is a federal requirement. For managed care Medicaid (MCO-based), the plan must first process an internal grievance before the state fair-hearing level.

42 CFR 431.221(d) ↗

Quick-reference table

Plan type	Internal appeal	Regulation
ERISA self-funded	180 days	29 CFR 2560.503-1
ACA commercial	180 days	45 CFR 147.136
Medicare Part A/B	120 days	42 CFR 405.942
Medicare Advantage	60 days	42 CFR 422.582
Medicaid	90 days minimum (state may extend)	42 CFR 431.221

Frequently asked questions

When does the appeal clock start?

From the date on the adverse benefit determination notice — the denial letter or the EOB. The clock does not start from the date of service or the date the original claim was submitted. If the notice is undated, document when you received it and start from that date.

What happens if I miss the deadline?

For most plan types, missing the internal appeal deadline closes the right to appeal — the claim becomes final. There are narrow exceptions: if the payer's notice was deficient (failed to include required appeal information), if the claimant was misled about the deadline, or if equitable tolling applies under ERISA. These exceptions require legal analysis and are rarely granted.

How do I know what type of plan a patient has?

The Summary Plan Description (SPD) or Evidence of Coverage (EOC) states whether the plan is self-funded under ERISA or fully-insured. The EOB or denial notice typically identifies the payer and the plan. For Medicare, the payer ID on the claim identifies whether it's a traditional Medicare contractor or a Medicare Advantage plan. When in doubt, call the payer's provider relations line and ask explicitly.

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