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 months from the final internal denial to file.

Under the 2026 CMS prior-authorization rule (CMS-0057-F), impacted payers — Medicare Advantage plans, Medicaid and CHIP (fee-for-service and managed care), and Qualified Health Plans on the federal Marketplace — must give a specific reason for a prior-authorization denial, not boilerplate. Ask for the exact criteria used, the guideline relied on, and the reviewer's credentials. A vague, non-specific denial gives you strong grounds to challenge the decision. (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.)