Plan-Type Framework

Which appeal rules apply to your denial?

Before medical necessity, before documentation, before anything else: the single biggest factor in a health insurance appeal is what kind of plan you have. Self-funded employer plans, fully-insured or individual ACA plans, and Medicare Advantage plans each run on a different rulebook, with different deadlines and different escalation paths.

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Why plan type comes first

Roughly two-thirds of people with employer coverage are in a self-funded plan administered under federal ERISA rules, not a fully-insured plan regulated by their state (67% of covered workers, per KFF's 2025 Employer Health Benefits Survey). Most members can't tell which one they have from their ID card alone; the underwriter's name on the card is often just the third-party administrator. Getting this wrong is the single most common error people make when researching their own appeal rights, because it leads them to the wrong deadline and the wrong escalation path.

Three Rulebooks

Compare the three plan-type frameworks

Identify which category your plan falls into before you research deadlines, escalation paths, or state-specific rights.

Self-Funded Employer Plan

Governed by ERISA

The employer pays claims directly and bears the financial risk, typically using a carrier's administrative-services arm (a TPA) to process claims. Buying stop-loss insurance does not convert a self-funded plan into a fully-insured one.

Governing rule: 29 U.S.C. § 1133; 29 CFR 2560.503-1 (U.S. Department of Labor / EBSA)
Internal appeal deadline: At least 180 days from the adverse benefit determination to file an internal appeal.
Decision timelines: 72 hours (urgent), 30 days (pre-service), 60 days (post-service).
External review: State external-review laws generally do not apply to self-funded benefits, since ERISA preempts most state insurance law here. Many non-grandfathered self-funded plans are subject to an applicable federal external-review framework instead, but this depends on the plan's grandfathered status and the specific rules that apply to it. Confirm the process in your denial notice and plan documents.

State mandates and state IMR/IRO programs generally do not apply to self-funded plans. If your appeal cites a state law your employer's plan doesn't follow, the carrier can disregard it. Ask HR or read the Summary Plan Description to confirm funding status first.

Fully-Insured & Individual (ACA) Plan

Governed by ACA + state law

The employer (or you, if you bought an individual/marketplace plan) pays a premium and the insurer bears the risk. These plans are primarily regulated by state insurance law, layered on top of the federal ACA floor.

Governing rule: 45 CFR 147.136 (non-grandfathered individual and group plans)
Internal appeal deadline: Plans must notify you of appeal rights on every adverse determination; final internal decisions are due within 60 days (standard) or 72 hours (urgent).
Decision timelines: 60 days (standard internal), 72 hours (urgent internal).
External review: 4 months from the final adverse determination to request review by an accredited Independent Review Organization (IRO). Standard IRO decisions are due within 45 days; expedited within 72 hours. The IRO reviews the claim from scratch and isn't bound by the carrier's prior decision.

This is the plan type where your state's specific rules matter most, and where the strongest state-specific overturn data applies (see below).

Medicare Advantage (Part C)

5-level federal ladder

A private Medicare Advantage plan administered by a commercial carrier (UnitedHealthcare, Aetna, Cigna, Humana, BCBS, and others) under contract with CMS.

Governing rule: 42 CFR Part 422, Subpart M
Internal appeal deadline: 65 days from the denial notice to request a Level 1 reconsideration by the plan.
Decision timelines: 7 calendar days for standard pre-service organization determinations (shortened from 14 days under CMS-0057-F, effective Jan. 1, 2026); 72 hours if expedited. Standard Level 1 reconsideration: 30 days; expedited: 72 hours.
External review: Denials upheld at Level 1 are automatically forwarded to an Independent Review Entity (IRE); you don't have to file anything separately for that step.

Of the ~4.1 million Medicare Advantage prior-authorization denials issued in 2024, only 11.5% were appealed, but 80.7% of those appeals were fully or partially overturned (KFF, July 2025). Appealing is disproportionately worth it for MA denials specifically.

Cited Outcomes

What actually happens when people appeal

Real, cited figures by track, never a generic success-rate claim.

80.7%

of appealed Medicare Advantage prior-authorization denials were overturned in 2024

KFF, July 2025

73%

of California DMHC Independent Medical Review cases resulted in the enrollee getting the requested service

DMHC 2024 Annual Report

46.7%

of New York DFS external appeals were overturned overall, rising to 52.5% in 2025

DFS data, via MedPage Today/MHANYS, April 2026

Medicare Advantage

The Medicare Advantage 5-level appeal ladder

Unlike ERISA or ACA plans, Medicare Advantage denials follow a fixed, five-level federal escalation path. Most disputes never need to go past Level 1 or 2.

Level 1

Reconsideration by the MA plan

File within 65 days of the denial notice. Standard decision in 30 days; expedited in 72 hours.
Level 2

Reconsideration by the Independent Review Entity (IRE)

The plan automatically forwards any denial it upholds; you generally don't file this step yourself.
Level 3

Administrative Law Judge (ALJ) hearing

Held at the Office of Medicare Hearings and Appeals (OMHA), subject to a minimum amount-in-controversy threshold.
Level 4

Medicare Appeals Council review

A further review of the ALJ's decision.
Level 5

Judicial review in federal district court

Must be filed within 60 days and requires a minimum amount in controversy.

Common Questions

Plan-Type FAQ

How do I find out if my employer plan is self-funded or fully-insured?

Your ID card usually won't say. Ask your employer's HR or benefits team directly, or check the plan's Summary Plan Description (SPD) for language about the employer bearing financial risk versus paying a premium to an insurer. Buying stop-loss insurance does not make a self-funded plan fully insured.

If I have a self-funded plan, do I lose my state's appeal rights entirely?

State insurance mandates generally regulate insurers, not the self-funded benefits an employer plan provides directly, so the state IMR/IRO program on your state's insurance-department website often won't apply the way it would to a fully-insured plan. You still have strong federal rights under ERISA's full-and-fair-review requirement and, for many plans, a federal external-review process. Check your plan's Summary Plan Description, and the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) is the federal resource for employer-plan claims questions.

Does this affect the deadline I should use?

Yes. Deadlines differ by plan type and stage of the appeal, and can also vary by state and carrier within those categories. Use our deadline calculator to estimate your specific window once you know your plan type, and confirm the exact date against your denial letter or EOB.

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This page provides general administrative information about how U.S. health insurance appeal rules typically vary by plan type. It is not legal advice. Appeal rights, deadlines, and escalation paths can vary by plan, employer, state, carrier, and date of service; always confirm against your plan documents and denial notice.