Employer Plans (ERISA): your appeal rights

If your health plan comes through a private employer, federal law gives you at least 180 days to appeal a denial. The plan must review your appeal fresh — with no deference to the original denial — and use a different decision-maker.

You're entitled — free of charge — to every document the plan used to deny you: the criteria, the internal notes, the reviewer's specialty. Ask for the complete claim file in writing. Plans that deny for medical reasons must consult a qualified health professional.

If the plan upholds a denial based on medical judgment, you can take it to an outside, independent review organization. The plan is bound by the outcome. You generally have 4 calendar months after receiving the adverse determination or final internal denial to file. Follow the notice and applicable calendar-date rules; do not substitute 120 days.

Under the 2026 CMS prior-authorization rule (CMS-0057-F), beginning January 1, 2026, impacted payers — Medicare Advantage plans, Medicaid and CHIP (fee-for-service and managed care), and Qualified Health Plans on the federal Marketplace — must include a specific reason when they deny a prior-authorization request for an item or service (drugs are excluded). You can also ask the plan for the criteria, guideline or policy it applied; that is a request, not something this rule requires. (This rule does not reach most commercial or self-funded employer/ERISA plans.)

Insurers must cover emergency care based on your symptoms at the time — not the final diagnosis. If a reasonable person would have thought it was an emergency, it must be covered as one, in or out of network, with no prior authorization required.

For emergency care and for out-of-network providers working at in-network facilities, you can only be billed your in-network cost sharing. Balance bills in those situations are illegal — dispute them rather than paying. (Ground ambulance bills are not covered by these protections.)