Urgent claims must be decided within 72 hours
When a delay could seriously jeopardise your life, health or ability to regain maximum function, or would subject you to severe pain, the plan must decide the claim within 72 hours and the appeal within 72 hours, and your treating clinician's judgment that the case is urgent binds the plan. Asking for expedited handling changes the clock.
When it applies
- Pre-service denials of imminent treatment: chemotherapy, surgery, inpatient stays, specialty drugs
- Continuing-care terminations
- Employer and marketplace plans; Medicare Advantage has an equivalent 72-hour expedited reconsideration
Where it does not
- Post-service claims (the care already happened; the dispute is money)
The sentence to put in the appeal
“This is a claim involving urgent care within the meaning of 29 CFR 2560.503-1(m)(1): [the treating physician has determined that] applying the standard timeframe could seriously jeopardise my [life / health / ability to regain maximum function]. Under sections (f)(2)(i) and (i)(2)(i), the plan must decide the claim and any appeal as soon as possible and no later than 72 hours after receipt, and must treat the physician's determination of urgency as controlling.”
Replace the bracketed parts with your facts. Cite the regulation exactly as written; quote the plan’s own wording next to it.
How to use it
- Step 1
Have the clinician say it is urgent, in writing
The rule makes the treating physician's judgment binding on the plan.
- Step 2
Mark everything 'expedited'
Subject lines, cover pages, fax headers. Plans route by label.
- Step 3
Run external review in parallel
Urgent cases may request expedited external review at the same time as the internal appeal.
Worked example
A chemotherapy regimen was denied nine days before the scheduled start. The oncologist certified urgency; the plan decided the expedited appeal in two days and approved.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
Go deeper
Sources
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