I received this denial. What happens next?

Questions people ask with the letter in their hand

How long do I have to appeal a denied health insurance claim?

It depends on the plan. Employer (ERISA) and ACA marketplace plans must give you at least 180 days from receipt of the denial to file an internal appeal (29 CFR 2560.503-1; 45 CFR 147.136). Medicare Advantage gives 60 days from receipt of the notice, and receipt is presumed 5 days after the notice date, so about 65 days from the date on the letter (42 CFR 422.582). Medicare Part D redeterminations run 60 days from receipt (42 CFR 423.582). Medicaid managed-care plan appeals are typically 60 days from the notice date (42 CFR 438.402), and state fair hearings are capped at 90 days from the notice mailing for direct Medicaid (42 CFR 431.221). The deadline printed on your letter controls.

What is the difference between an internal appeal and an external review?

An internal appeal asks the plan to reconsider its own decision; the plan must decide within 30 days for care you have not yet received, 60 days for a bill, or 72 hours if urgent. An external review sends a medical-judgment denial to an independent reviewer whose decision binds the plan. For ERISA and marketplace plans you generally have four months after the final internal denial to request it (45 CFR 147.136). Medicare Advantage forwards an upheld denial to the Independent Review Entity automatically.

My parent got a Notice of Medicare Non-Coverage (NOMNC). How fast do we have to act?

Very fast. The NOMNC tells you to contact the Quality Improvement Organization (QIO) no later than noon of the day before the effective date printed on the notice; the regulations phrase it as noon of the first day after the notice is delivered (42 CFR 422.626 for Medicare Advantage; 42 CFR 405.1200-405.1206 for Original Medicare). Call the QIO number on the notice by phone; the QIO decides within about 72 hours and coverage generally continues while it reviews. For a hospital discharge, request immediate QIO review no later than the day of discharge (42 CFR 422.622).

Does the appeal deadline count from the date on the letter or the day I received it?

Most federal rules count from the day you received the notice, and Medicare presumes receipt 5 days after the notice date. Counting from the date printed on the letter is the safe, conservative choice; treat any extra days as a cushion, not a plan. If the letter states a specific date, that date governs.

Is Apellica a law firm?

No. Apellica is an appeal-preparation and filing service, not a law firm, and does not give legal advice. Appeals are prepared and filed in your name with your written authorization, at $0 upfront and a percentage of what is recovered only if the appeal succeeds. If you need legal advice, consult a licensed attorney in your state; state consumer-assistance programs and legal-aid offices also help free of charge.