How to appeal a Health Care Service Corporation denial
Start with the reason on your denial notice. Check your plan’s appeal route, then gather the records that answer the specific coverage rule.
No account or payment to check your route. You confirm the plan facts; published review outcomes do not predict your result.
Your appeal path depends on which kind of Health Care Service Corporation plan you have. Find the matching plan below. Use the filing instructions on your actual notice.
Worth knowing before you start: 80% of appealed denials in Health Care Service Corporation’s published Medicare Advantage Blue plans scope were overturned in reporting year 2025.
SOURCE: Health Care Service Corporation published prior-authorization metrics ↗ · scope and methodology
Medicare Advantage
You 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.
Level 1 — Plan reconsideration
The plan or designated delegated entity must receive the appeal within 60 calendar days after you receive the denial notice. Receipt of the notice is presumed 5 days after its date unless evidence shows otherwise (a 65-day notice-date default). The plan must use a different reviewer; medical denials need a physician reviewer.
Level 2 — Independent Review Entity (automatic)
If the plan says no again, it MUST forward your case to an outside reviewer automatically. You do nothing.
Level 3 — Administrative Law Judge
60 days to request a hearing if the amount in dispute meets the threshold.
ACA / Marketplace Plans
You bought your plan on healthcare.gov or a state exchange, or you have an individual (non-employer) plan regulated by the Affordable Care Act.
Step 1 — Internal appeal
180 days to file. Plan decides in 30 days (pre-service) or 60 days (post-service); 72 hours if urgent.
Step 2 — External review
State or federal HHS process depending on your state. Independent, binding, 4 months to file.
In parallel — state insurance department complaint
Your state DOI takes consumer complaints and can pressure insurers on process violations.
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.
Step 1 — Internal appeal
180 days to file. New decision-maker, no deference to the original denial, qualified medical reviewer for clinical denials.
Step 2 — External review
Independent review organization for medical-judgment denials. Binding on the plan. 4 months to file.
Step 3 — Federal court (ERISA § 502)
Lawsuit to recover benefits. The record you built in the internal appeal is usually the ONLY evidence the court sees — build it well.