ERISA appeal rights: what your employer-sponsored plan owes you
If your coverage comes through a job, ERISA sets the floor for how denials must be handled, what the plan must disclose, and how long you have to appeal.
What ERISA covers
ERISA (the Employee Retirement Income Security Act) governs most private-sector, employer-sponsored group health plans. It does not cover Medicare, Medicaid, individual marketplace plans, or church and government plans.
The federal claims procedure for ERISA plans is codified at 29 CFR 2560.503-1. It sets minimum standards for how a plan handles claims, denials, and appeals — your plan's Summary Plan Description can give you more rights but cannot give you less.
Disclosures the plan owes you on request
All documents, records, and other information relevant to the claim, free of charge. That includes the clinical policy or coverage rule the plan applied.
The identity of any medical or vocational expert whose advice was obtained, even if the plan did not rely on it.
Any internal rule, guideline, protocol, or similar criterion used in the denial.
Source: 29 CFR 2560.503-1(h)(2)(iii)–(iv) and (m)(8). See https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/subchapter-L/part-2560/section-2560.503-1.
Deadlines that bind the plan
Pre-service claims: decision within 15 days; one 15-day extension allowed for matters beyond the plan's control.
Urgent care claims: decision as soon as possible, no later than 72 hours.
Post-service claims: decision within 30 days; one 15-day extension allowed.
Internal appeals: 180 days for you to file from the date of denial; the plan must decide a pre-service appeal within 30 days and a post-service appeal within 60 days.
Source: 29 CFR 2560.503-1(f) and (i).
After the final internal denial
Most non-grandfathered ERISA plans must offer external review under 45 CFR 147.136. You have 4 months (about 120 days) from the final internal denial to request it.
If the plan fails to follow the procedure (missed deadlines, no required disclosures, no claims-procedure notice) you may be able to skip remaining internal levels and proceed straight to court or external review under the deemed-exhaustion rule at 29 CFR 2560.503-1(l).
Upload the denial letter. Free analysis first, finished letter second.
FAQ
Is my plan ERISA or fully insured?+
Most large-employer plans are self-funded ERISA plans. Small-employer and individual plans are usually fully insured and governed by state law plus the ACA. The Summary Plan Description names the plan administrator and funding type.
Can the plan ignore the deadlines?+
No. Failure to meet the claims-procedure deadlines can let you treat the claim as exhausted and go to external review or court. See 29 CFR 2560.503-1(l).
More guides
- How to write a health insurance appeal letter
- Internal appeal vs external review: what is the difference
- Expedited appeals: when to ask for an urgent review
- The No Surprises Act and out-of-network bills