Written by a parent, not a doctor. Nothing here is medical advice.

Childhood Cancer Lantern
Search Saved

Federal, exists in every state

Fight a denial (appeals inside the plan and outside it)

Official name: Health Plan Internal and External Review

You can challenge a health plan or Medicaid denial in writing. Ask for urgent review when waiting is dangerous; an outside reviewer can overrule the plan.

A denial overturned, inside 72 hours when waiting is dangerous.

Program details

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Read the denial's date and option, file the written appeal (marked urgent if treatment is waiting), and for Medicaid ask for the service to continue within 10 days.

Your social worker

Identifies the right appeal office and deadline and helps assemble the file.

The care team

Writes the letter that answers the denial's stated reason and marks it urgent when delay is unsafe.

Who decides
The plan, then an independent external reviewer or a state hearing officer
Ask the care team
“The plan denied this. Can you write a letter answering their stated reason, and can we file it as an urgent appeal so they must decide in 72 hours?”

How to apply

First step: Read the denial's date and option today. Ask the oncologist for a letter answering the stated reason, and file the written appeal marked “urgent” if treatment is waiting.

  1. Get the decision in writing with its date.
  2. Ask the clinician for a letter answering the stated reason.
  3. File marked urgent when treatment is waiting. For Medicaid ask for benefits to continue within 10 days.

Where it starts: Written appeal as the notice directs. Urgent marked as such

What to gather

  • The denial letter and envelope
  • The plan's clinical policy the denial cites
  • The clinician's letter of medical necessity answering that policy

How long: Urgent: 72 hours. A Medicaid plan appeal: 30 days. Federal external review: 45 days, or 72 hours when urgent.

Clock: File the internal appeal within 180 days of the denial (private plan).

Clock: Ask within 10 days for the service to continue during the appeal.

What a yes looks like

A written reversal or a revised approval. Confirm the start date with the provider.

What a no looks like, and the next move

The letter names the next level: external review (private plans) or a state fair hearing (Medicaid). Keep going. Each level is a new reviewer.

Watch out

  • Private plan: 180 days to file the internal appeal. 72 hours for an urgent decision. The letter names the external review option (state or federal).
  • Medicaid managed care: 60 days to appeal to the plan, decided in 30 days (72 hours expedited), then a state fair hearing. Ask for benefits to continue within 10 days of the notice.
  • A phone complaint is not an appeal. Put it in writing, keep the envelope, and get the clinician's letter answering the denial's exact reason.
  • FEHB: carrier reconsideration generally has a six-month filing window, followed by OPM review under the denial notice. Self-funded state/local plans can use an approved federal review route; it is not always HHS-administered. Use the current notice for the filing deadline.
  • Governmental-plan exemptions from some benefit rules do not create a general opt-out from applicable appeal rules. Mental-health-parity opt-outs have ended apart from a narrow qualifying collective-bargaining transition; ask the administrator to identify any claimed exception.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 10, 2026.

What it is worth

A second look at a denied drug, transplant center, nursing or scan. A decision within 72 hours when urgent. Medicaid benefits kept running during an appeal.

Legal protection: Private plan: internal appeal within 180 days of the denial. Urgent decisions within 72 hours. External review after (45 days, or 72 hours when urgent) · Medicaid managed care: 60 days to appeal to the plan. Decided within 30 days, 72 hours expedited. Then a state fair hearing · Medicaid: benefits continue when the appeal is requested within 10 days of the notice (receipt presumed 5 days after the date) · Access to the plan's rationale and clinical policy

What it costs the family: No plan appeal fee.

The eligibility facts, as published

Adverse benefit determination
yes

Decisions this site cannot make: Appeal eligibility · Medical necessity · Plan terms

Expect friction on: Deadlines on the letter · The appeal process depends on the plan type · Clinical evidence

The trap: A phone complaint is not an appeal. Put it in writing, keep the envelope, and get the clinician's letter answering the denial's exact reason.

What changes by state: The external-review option for a fully insured plan (state regulator or the federal process) and the fair-hearing period for Medicaid (60–120 days).

Where I read this

← Pick your state