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Your appeal rights, by plan type
A denial notice should explain an appeal route, but the rules and deadlines depend on the exact coverage program and benefit channel. Pick the plan shown on the card or notice; use the free router when you are unsure.
Original Medicare (Parts A & B)You use Original Medicare directly for Part A or Part B, rather than a private Medicare Advantage plan. Your Medicare Summary Notice identifies the claim and the Medicare contractor.Medicare Part D (standalone drug plan)A standalone Medicare prescription-drug plan denied a pharmacy-benefit drug, formulary exception, tiering exception, quantity limit, or step-therapy request.Medicare AdvantageYou have a Medicare plan run by a private insurer (an “MA” or “Part C” plan) — the card says Medicare Advantage, and the insurer is a company like UnitedHealthcare, Humana, or Aetna.Employer Plans (ERISA)Your insurance comes through a private-sector job — yours or a family member's. Most working-age Americans with employer coverage are in an ERISA plan, even when a big-name insurer administers it.ACA / Marketplace PlansYou bought your plan on healthcare.gov or a state exchange, or you have an individual (non-employer) plan regulated by the Affordable Care Act.MedicaidYour coverage is Medicaid or CHIP — often through a managed care company (Centene, Molina, UnitedHealthcare Community Plan, and others run state Medicaid plans).
Not sure which plan you have?
- You receive Medicare Summary Notices and did not join a private plan — use Original Medicare’s Part A/B claim appeal.
- Card mentions Medicare, Part C, or Medicare Advantage— you have a Medicare Advantage plan, even though the card carries an insurer’s logo.
- A standalone Medicare drug plan denied a pharmacy prescription — use the Part D coverage-determination and appeal track. A clinician-administered drug may instead be a Part B medical-benefit denial.
- Coverage comes through a job— yours or a family member’s — check the plan document for private, government, church, or union sponsorship and for “self-funded,” “self-insured,” or “ASO.” Do not assume government or church coverage follows ordinary ERISA or state rules.
- You bought it on HealthCare.gov or a state exchange— it’s a marketplace (ACA) plan.
- Your state’s Medicaid program pays — often through a managed-care company whose name is on the card — Medicaid rules apply.
- The card or brochure says FEHB or TRICARE — use that federal program’s own instructions, not an ERISA or state-insurance template.
Still unsure? Use the Coverage Pathway Router. It will identify missing facts rather than assigning a state or federal route from residence alone.
State external review
Eligible state-regulated plans may offer binding external review after an internal appeal. Self-funded employer plans and federal programs use different routes, and current availability can change. Confirm eligibility, jurisdiction, and the deadline against the denial notice and regulator source.