Federal appeal timeline requirements
The Affordable Care Act sets minimum timelines for insurance appeal decisions that apply to all non-grandfathered health plans. For internal appeals: standard reviews must be decided within 30 days; urgent (expedited) reviews must be decided within 72 hours. For external reviews: standard external reviews must be decided within 45 days; urgent external reviews must be decided within 72 hours. These are the federal minimums — your plan or state may have faster requirements. The clock starts when the insurer receives your complete appeal package.
What counts as an "urgent" appeal
An appeal qualifies as urgent (expedited) when following the standard timeline would seriously jeopardize your health or your ability to regain maximum function. Examples include: ongoing inpatient care being denied, cancer treatment that cannot be delayed, medications for serious chronic conditions, mental health crises, and post-surgery care denials. Your doctor must certify the urgency in writing. If your doctor says it's urgent, the insurer must treat it as an expedited appeal.
Standard vs. urgent appeals — choosing the right track
Most routine denials go through standard review. But if your condition is serious, don't automatically accept standard timelines. A 30-day wait for a cancer treatment decision or a mental health inpatient authorization can cause real harm. Have your doctor write a sentence in the appeal letter or letter of medical necessity stating: "Given the clinical urgency of [patient]'s condition, I request that this appeal be processed on an expedited basis. Delay of [treatment] would [specific clinical consequence]." This triggers the 72-hour decision requirement.
State-by-state additional appeal protections
Many states have enacted appeal timelines stricter than federal requirements. California's Department of Managed Health Care requires Independent Medical Reviews within 30 days (not 45) for standard cases and within 3 days for urgent cases. New York's Department of Financial Services requires expedited appeals within 72 hours and has additional consumer advocate resources. Texas requires HMOs to decide standard utilization reviews within 3 business days and urgent reviews within 1 business day. Washington state requires prior authorization decisions within 3 business days for non-urgent and 1 business day for urgent requests. Check your state insurance commissioner's website for current requirements.
States with the fastest appeal requirements
California offers the fastest external review in the country through the DMHC — 30 days standard, 3 business days urgent, and the process is entirely free. New York provides a dedicated external appeal process through the New York State External Appeal Program that matches California's speed. Florida, Texas, and Illinois each have state-specific prior authorization reform laws enacted since 2020 that include stricter decision timelines for PA requests.
What happens if your insurer misses the decision deadline
If your insurer fails to decide your appeal within the required timeframe, you have several options: you can immediately request external review without waiting for the internal appeal decision, file a complaint with your state insurance commissioner for the deadline violation, and in some states, the deadline violation itself means the appeal is automatically decided in your favor. Document the deadline and date of your appeal submission carefully. If the insurer misses the deadline, send a letter noting the specific regulatory timeframe that was violated and your intent to escalate.
Medicare and Medicaid appeal timelines
Medicare appeals have different timelines than commercial insurance. For Medicare Advantage, internal reviews must be completed within 60 days for standard and 72 hours for expedited. For Medicare Part D drug denials, the standard review takes 7 days and expedited reviews take 72 hours. Medicaid timelines vary by state — generally 90 days to appeal with a decision within 90 days, though many states have shorter timelines. Medicare beneficiaries can also request a redetermination (the first level of Medicare appeal) within 120 days of a coverage denial.