Aetna Appeal Deadline: How Long Do I Have to Appeal an Aetna Denial?
For most Aetna commercial and ACA plans you have 180 days from the denial to file an internal appeal, and generally at least 4 months (120 days) after the final internal denial to request external review. Deadlines by plan type, what starts the clock, and the caveats that change the date.
For most Aetna commercial and ACA (non-grandfathered) plans, you have 180 days from the date of the denial notice to file a Level 1 internal appeal, and generally at least 4 months (about 120 days) from the final internal denial to request an external review by an Independent Review Organization. Aetna limits external review to denials involving more than $500 and based on medical necessity or an experimental/investigational determination. Medicare Advantage appeals run on the federal 60-day reconsideration clock instead, and Medicaid (Aetna Better Health) runs on your state's fair-hearing clock. The exact deadline that binds you is printed on your denial letter and in your plan documents — always confirm it there.
Aetna, owned by CVS Health, administers commercial group plans, ACA marketplace coverage, Medicare Advantage, and Medicaid managed care (Aetna Better Health), plus a large pharmacy benefit through CVS Caremark. Which appeal clock applies to you depends entirely on which of those product lines your plan sits in — and the deadline for one line is the wrong deadline for another. This page lays out each window, what event starts it, and the exceptions that can shorten or extend it. For Aetna denial patterns, criteria-disclosure, and the overall appeal strategy, see our Aetna overview; this page is only about the clock.
Aetna appeal deadlines at a glance
The table below is the fast answer. Every window is a floor set by federal law or by Aetna's published member documents; your specific plan can allow longer, and your denial letter is the controlling statement of the date.
| Plan type | Internal appeal window | External / next review | Clock starts when | Source |
|---|---|---|---|---|
| Commercial / ACA (non-grandfathered) | 180 days for Level 1; 60 days to request Level 2 after a Level 1 denial | Generally at least 4 months (≈120 days) for external review (denials over $500, medical-necessity or experimental basis) | Date you receive the denial notice / EOB | Aetna member claim-denial page; 45 CFR §147.136 |
| Self-funded / ERISA (Aetna as ASO administrator) | At least 180 days (ERISA floor); the plan document can allow longer | Federal external review or plan-specified process; confirm in the SPD | Date of the adverse benefit determination notice | 29 CFR §2560.503-1 |
| Medicare Advantage (Aetna Medicare) | 60 days to request a Level 1 reconsideration | Auto-forward to the Independent Review Entity (Maximus) on an upheld denial; then ALJ, Council, court | Date of the plan's coverage determination notice | 42 CFR §422.582 |
| Medicaid (Aetna Better Health) | State-specific, commonly 60-120 days for the plan appeal | State fair hearing after the plan appeal | Date of the plan's action / adverse benefit notice | 42 CFR §431.221 (state Medicaid rules) |
The commercial / ACA clock: 180 days internal, ~4 months external
For Aetna's individual, family, and employer commercial plans that are ACA non-grandfathered, the federal internal-appeal floor is 180 days from the date you receive the denial. Aetna's own member materials state members have 180 days from receiving the notice of a denied claim to file an appeal, unless the plan brochure or Summary Plan Description gives longer.
A Level 1 appeal is reviewed internally by Aetna's medical directors. Aetna's published timeframes for the decision are generally 30 days for a pre-service (not-yet-received) service and 60 days for a post-service claim. If Level 1 is denied and your plan offers a Level 2 review, you generally have 60 days from the Level 1 decision to request it.
After the internal appeals are exhausted, external review by an Independent Review Organization is a separate, binding lane. Under the federal ACA standard you generally have at least 4 months (about 120 days) from the final internal denial to request it. Aetna additionally limits its external-review program to denials involving more than $500 that turn on medical necessity or an experimental/investigational determination; the IRO generally decides within 30 days.
Self-funded (ERISA) Aetna plans work differently
A large share of Aetna commercial members are actually in a self-funded employer plan where Aetna is only the third-party administrator (ASO). These plans are governed by ERISA, not the ACA insurance rules, so the deadline lives in the plan's Summary Plan Description. The ERISA floor is at least 180 days to appeal, and many plans mirror the ACA external-review process, but some route to a plan-specific final decision instead.
If your ID card or SPD names your employer as the plan sponsor and describes the plan as self-insured, treat the SPD as controlling and read the appeals section before you rely on any general number. Our ERISA appeals hub explains how to identify a self-funded plan and how the ERISA claims-procedure regulation (29 CFR §2560.503-1) changes your rights and your carrier's obligations.
Medicare Advantage and Medicaid: separate clocks
If your Aetna plan is a Medicare Advantage plan, the commercial 180-day window does not apply. You have 60 days from the plan's coverage determination to request a Level 1 reconsideration, and the federal 5-level Medicare ladder (plan reconsideration → Independent Review Entity/Maximus → Administrative Law Judge → Medicare Appeals Council → federal court) takes over. An upheld plan reconsideration is forwarded automatically to the IRE.
If your coverage is Aetna Better Health (Medicaid managed care), your deadline is set by your state's Medicaid program, commonly 60-120 days for the plan-level appeal, followed by a state fair hearing. Many states also require you to file within about 10 days of the action notice to keep a previously authorized service in place while you appeal.
Expedited and urgent timelines
When waiting the standard timeframe could seriously jeopardize your health, you can request an expedited (urgent) appeal. Aetna, like all ACA-governed carriers, must resolve an urgent internal appeal quickly — generally within 72 hours — and urgent external reviews are similarly compressed. The filing deadline to start the appeal is the same 180 days; the urgent flag speeds the carrier's response, not your window to file.
Have the treating physician sign off on the urgency in writing. That is what converts a standard timeline into an expedited one.
Practical next steps
Required documents
- The denial letter or EOB showing the reason and the deadline
- Your member ID and the claim or authorization number
- A Letter of Medical Necessity from the treating physician addressing Aetna's Clinical Policy Bulletin criteria point by point
- Supporting clinical records, test results, and prior-treatment history
- Proof of timely filing (certified-mail receipt, fax confirmation, or portal submission screenshot)
Your plan documents and denial letter control
The windows on this page are the federal and published-policy floors. Your specific plan can give you longer, and a self-funded ERISA plan can define its own process within the ERISA minimums. The single controlling date is the deadline printed on your Aetna denial letter, read together with your Summary Plan Description or Evidence of Coverage. If those documents disagree with anything here, follow them, and if the letter omits a deadline, that omission is itself worth raising in the appeal.
Frequently asked questions
How long do I have to appeal an Aetna denial?
For most Aetna commercial and ACA plans, 180 days from the date you receive the denial notice to file a Level 1 internal appeal. Medicare Advantage plans use a 60-day reconsideration window instead, and Medicaid (Aetna Better Health) uses your state's fair-hearing deadline. Always confirm the date on your denial letter.
How long do I have to request an Aetna external review?
Under the federal ACA standard, generally at least 4 months (about 120 days) from the final internal denial. Aetna limits external review to denials involving more than $500 that are based on medical necessity or an experimental/investigational determination; the Independent Review Organization generally decides within 30 days.
Does the clock start on the denial date or when I receive the letter?
Aetna's member materials measure the 180 days from when you receive the notice of the denied claim. Because that can be hard to prove, the safest practice is to treat the date printed on the letter as day one and file well before the deadline.
What if my Aetna plan is through my employer and self-funded?
Then it is governed by ERISA, and the deadline is in your Summary Plan Description. The ERISA floor is at least 180 days to appeal, but the SPD is controlling — read its appeals section before relying on any general number. See our ERISA appeals hub.
Can I get an expedited Aetna appeal?
Yes. If waiting could seriously jeopardize your health, your physician can certify the urgency and Aetna must resolve an expedited internal appeal quickly — generally within 72 hours. The filing deadline is unchanged; the urgent flag speeds the decision.
I missed the 180-day window — is my appeal dead?
Not necessarily. Some plans allow a longer period, good cause can sometimes excuse a late filing, and procedural failures by the carrier (such as an incomplete denial notice) can reopen the record. Check your plan documents and the denial letter, and don't assume the deadline is fatal without confirming.
Sources
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