# Health insurance denials and appeals: research log

Research by Known Quantity LLC for /for-good/insurance-denial/. Started and checked 2026-11-13.
Rule: every deadline, phone number and statistic on the page traces to a row here (row ids D1, D2, ...). Quotes are kept under 15 words.

How sources were read: WebFetch (page text extracted by a reader model) and WebSearch, on 2026-11-13. The shell could not reach these sites directly. Where a reader summary gave a figure, the figure was matched against a second source where one exists (noted in the row).

This log is general information, not legal advice. Plans, states and letters differ. The denial letter and the plan's own documents control.

## Sources

| id | Title | Date | Publisher | URL | Kind |
|---|---|---|---|---|---|
| R1 | 29 CFR 2560.503-1, Claims procedure (ERISA job-based plans) | current text, read 2026-11-13 | Code of Federal Regulations, via Cornell LII | https://www.law.cornell.edu/cfr/text/29/2560.503-1 | Primary (regulation) |
| R2 | 29 CFR 2590.715-2719, Internal claims and appeals and external review processes (ACA rules for group plans and insurers) | current text, read 2026-11-13 | Code of Federal Regulations, via Cornell LII | https://www.law.cornell.edu/cfr/text/29/2590.715-2719 | Primary (regulation) |
| R5 | 45 CFR 147.136, Internal claims and appeals and external review processes (HHS; individual market), 2020 annual edition | 2020 edition, read 2026-11-13 | GovInfo (Code of Federal Regulations) | https://www.govinfo.gov/content/pkg/CFR-2020-title45-vol2/pdf/CFR-2020-title45-vol2-sec147-136.pdf | Primary (regulation) |
| R3 | 42 CFR 438.402, Medicaid managed care: grievance and appeal system, general requirements | current text, read 2026-11-13 | Code of Federal Regulations, via Cornell LII | https://www.law.cornell.edu/cfr/text/42/438.402 | Primary (regulation) |
| R4 | 42 CFR 431.221, Medicaid fair hearings: request for hearing | current text, read 2026-11-13 | Code of Federal Regulations, via Cornell LII | https://www.law.cornell.edu/cfr/text/42/431.221 | Primary (regulation) |
| G1 | Internal appeals | read 2026-11-13 | HealthCare.gov (CMS) | https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ | Primary (government guidance) |
| G2 | External review | read 2026-11-13 | HealthCare.gov (CMS) | https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ | Primary (government guidance) |
| G3 | Internal Claims and Appeals and the External Review Process: Overview (CSG-202608) | August 2026 | CMS | https://www.cms.gov/files/document/internal-claims-appeals-external-review-process-overview.pdf | Primary (government guidance) |
| G4 | Benefit Claims Procedure Regulation FAQs | read 2026-11-13 | U.S. Department of Labor, EBSA | https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/benefit-claims-procedure-regulation | Primary (government guidance) |
| G5 | Ask EBSA (contact page; dol.gov link redirects to beta.dol.gov) | read 2026-11-13 | U.S. Department of Labor, EBSA | https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa | Primary (government) |
| G6 | Appeals in Original Medicare | read 2026-11-13 | Medicare.gov | https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/original-medicare | Primary (government guidance) |
| G7 | First Level of Appeal: Redetermination by a Medicare Contractor | last modified 2026-03-10 | CMS | https://www.cms.gov/medicare/appeals-grievances/fee-for-service/first-level-appeal-redetermination-medicare-contractor | Primary (government guidance) |
| G8 | Appeals in Medicare health plans | read 2026-11-13 | Medicare.gov | https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/health-plans | Primary (government guidance) |
| G9 | Reconsideration by the Medicare Advantage (Part C) Health Plan | last modified 2025-01-07 | CMS | https://www.cms.gov/medicare/appeals-grievances/managed-care/reconsideration-advantage-health-plan-part-c | Primary (government guidance) |
| G10 | Where Can People Get Help With Medicaid & CHIP? (state agency contacts) | read 2026-11-13 | Medicaid.gov | https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip | Primary (government) |
| G11 | State Health Insurance Assistance Program: About us | read 2026-11-13 | SHIP Technical Assistance Center (ACL-funded) | https://www.shiphelp.org/about-us | Program site |
| G12 | State Health Insurance Assistance Program (SHIP) | read 2026-11-13 | Administration for Community Living | https://acl.gov/programs/connecting-people-services/state-health-insurance-assistance-program-ship | Primary (government) |
| G13 | Consumer Assistance Program (CAP Grants) | last modified 2026-03-13 | CMS | https://www.cms.gov/marketplace/about/affordable-care-act/consumer-assistance-program-grants-cap | Primary (government) |
| G14 | Transparency in QHP Coverage Public Use File Data Dictionary, PY2027 (plan year 2025 data) | read 2026-11-13 | CMS CCIIO | https://www.cms.gov/files/document/transparency-coverage-datadictionary-py27.pdf | Primary (government data) |
| K1 | Claims Denials and Appeals in ACA Marketplace Plans in 2024 (Michelle Long, Justin Lo, Kaye Pestaina) | 2026-03-24 | KFF | https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/ | Research (analysis of CMS data) |
| K2 | Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024 (Jeannie Fuglesten Biniek, Nolan Sroczynski, Meredith Freed, Tricia Neuman) | 2026-01-28 | KFF | https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/ | Research (analysis of CMS data) |
| K3 | Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain | 2026-08-13 | KFF | https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/ | Research |
| M1 | DataPoints Issue 33: Evidence of Administrative Complexity: Health Insurance Claim Denials in Massachusetts | 2026-02-05 | Massachusetts Health Policy Commission | https://masshpc.gov/sites/default/files/Datapoints_OPP%20claims%20denials_33_0.pdf | Primary (state agency) |

## A. Job-based plans and Marketplace (ACA) plans: internal appeal

Who: most job-based plans (ERISA, R1) and non-grandfathered group and individual coverage (R2, G1, G3). Government employer plans and church plans are not ERISA plans; grandfathered plans are generally outside R2 (R2 (a)(1)(ii)). The page tells people to check the letter.

| id | Claim | Figure | Applies to | Source | Quote (under 15 words) / note |
|---|---|---|---|---|---|
| D1 | Time to file an internal appeal | at least 180 days after receiving the denial notice | Job-based group health plans | R1 (h)(3)(i); G4 D-5 | G4: "at least 180 days following receipt of an adverse benefit determination" |
| D2 | Time to file an internal appeal, Marketplace and individual plans | 180 days (6 months) of receiving the notice | Marketplace / individual plans | G1; G3 | G1: "within 180 days (6 months) of receiving notice that your claim was denied" |
| D3 | Decision time, urgent care appeal | no later than 72 hours after the request | Group health plans; non-grandfathered plans | R1 (i)(2)(i); G3 | R1: "not later than 72 hours after receipt of the claimant's request". G3: "Maximum 72 hours". Note: G1 (HealthCare.gov) instead says "at least within 4 business days"; the page uses the regulation and CMS overview figure (72 hours) and does not repeat G1's wording. |
| D4 | Decision time, appeal of care not yet received (pre-service) | 30 days (one appeal level); 15 days per level if the plan has two levels | Group plans; Marketplace | R1 (i)(2)(ii); G1; G3 | G1: "completed within 30 days ... for a service you haven't received yet" |
| D5 | Decision time, appeal of care already received (post-service) | 60 days (one level); 30 days per level if two levels | Group plans; Marketplace | R1 (i)(2)(iii)(A); G1; G3 | G1: "completed within 60 days ... for a service you've already received" |
| D6 | Definition of urgent care claim | standard time limits could seriously jeopardize life or health (or other criteria in (m)(1)(i)(B)) | Group plans | R1 (m)(1)(i) | "Could seriously jeopardize the life or health of the claimant" |
| D7 | Right to free copies of documents relevant to the claim | free of charge, on request | Group plans (and by R2, non-grandfathered coverage) | R1 (h)(2)(iii); G4 D-11 | G4: "upon request and free of charge, reasonable access to, and copies of, all documents" |
| D8 | Right to the internal rule, guideline or protocol relied on | provided free of charge on request | Group plans | R1 (g)(1)(v)(A); G4 C-16, C-17; G3 | R1: "will be provided free of charge to the claimant upon request" |
| D9 | Right to an explanation of the clinical judgment for medical-necessity or experimental denials | free of charge on request | Group plans | R1 (g)(1)(v)(B) | "such explanation will be provided free of charge upon request" |
| D10 | Right to submit written comments, documents and other information | yes | Group plans | R1 (h)(2)(ii) | "opportunity to submit written comments, documents" |
| D11 | Appeals involving medical judgment must consult an appropriately trained health professional; plan must identify medical experts whose advice it obtained | yes | Group plans | R1 (h)(3)(iii), (h)(3)(iv) | "identification of medical or vocational experts" |
| D12 | Plan must give, free, any new or additional evidence it considered or generated | yes | Non-grandfathered coverage | R2 (b)(2)(ii)(C) | "free of charge, with any new or additional evidence considered" |
| D13 | Denial notice must identify the claim (date of service, provider, claim amount) | yes | Non-grandfathered coverage | R2 (b)(2)(ii)(E)(1) | "the date of service, the health care provider, the claim amount" |
| D14 | Denial notice must describe internal appeal and external review processes | yes | Non-grandfathered coverage | R2 (b)(2)(ii)(E)(4) | "a description of available internal appeals and external review processes" |
| D15 | Denial notice must give contact information for any consumer assistance office or ombudsman | yes | Non-grandfathered coverage | R2 (b)(2)(ii)(E)(5) | "contact information for, any applicable office of health insurance consumer assistance" |
| D16 | Continued coverage pending the outcome of an appeal | required | Non-grandfathered coverage (ongoing treatment) | R2 (b)(2)(iii); G3 | G3: "required to provide continued coverage pending the outcome of an appeal" |
| D17 | If the plan does not follow the rules, the internal appeal can be treated as done ("deemed exhausted") | yes, with a narrow exception for minor errors | Non-grandfathered coverage | R2 (b)(2)(ii)(F)(1); G3 | Not shown as advice on the page beyond "ask about it" |
| D19 | Individual-market insurers must follow the ERISA claims and appeals rules (29 CFR 2560.503-1), must give new evidence free of charge, and must let the claimant review the claim file | yes | Individual health insurance, incl. Marketplace (non-grandfathered) | R5 (b)(3)(i), (b)(3)(ii)(C) | "must comply with all the requirements of the ERISA internal claims and appeals procedures"; "allow a claimant to review the claim file". 2020 edition read; current text not opened (see below). Cited in the Marketplace version of the letter. |
| D18 | Initial decision times (for context): urgent 72 hours; pre-service 15 days; post-service 30 days | | Group plans | R1 (f)(2)(i), (f)(2)(iii)(A)-(B); G1; G3 | Not a step on the page; background only |

## B. Job-based and Marketplace plans: external review

| id | Claim | Figure | Applies to | Source | Quote / note |
|---|---|---|---|---|---|
| D20 | Time to ask for external review after the final internal denial | 4 months after receiving the notice (federal process); state processes must allow at least 4 months | Non-grandfathered coverage | R2 (d)(2)(i), (c)(2)(vi); G2; G3 | G2: "within 4 months after the date you receive a notice or final determination" |
| D21 | Standard external review decision | no later than 45 days after the request is received | Non-grandfathered coverage | G2; G3 | G2: "no later than 45 days after the request was received" |
| D22 | Expedited external review decision | no later than 72 hours, or less | Non-grandfathered coverage | G2; G3 | G2: "no later than 72 hours, or less" |
| D23 | Urgent cases may ask for internal appeal and external review at the same time | yes | Non-grandfathered coverage | G3 | "initiate an internal appeal and external review simultaneously" |
| D24 | Cost of external review | none in the HHS-run process; otherwise at most $25 | Non-grandfathered coverage | G2 | "the charge can't be more than $25 per external review" |
| D25 | HHS-administered federal external review contact | 1-888-866-6205 (request form); email ferp@maximus.com | Plans in the HHS-administered process only | G2 | Shown on the page only with "if your letter says your plan uses the federal process" |
| D26 | Grandfathered plans: external review rules generally do not apply (some No Surprises Act claims excepted) | | Grandfathered plans | R2 (a)(1)(ii); G3 | Page says "check your letter" |

## C. Medicare

| id | Claim | Figure | Applies to | Source | Quote / note |
|---|---|---|---|---|---|
| D30 | Original Medicare level 1 (redetermination) filing time | 120 days from receipt of the initial determination; notice presumed received 5 days after its date | Original Medicare (Parts A and B) | G7 | "120 days from the date of receipt of the initial claim determination". Medicare.gov (G6) says: "You must file your appeal by the date in the MSN." The page says both: use the date on your Medicare Summary Notice. |
| D31 | Original Medicare level 1 decision time | generally within 60 days | Original Medicare | G6; G7 | G6: "generally get a decision ... within 60 days" |
| D32 | Original Medicare level 2 (reconsideration by a Qualified Independent Contractor) filing time | 180 days after the level 1 decision letter | Original Medicare | G6 | "You have 180 days after you get the MAC's decision letter" |
| D33 | Original Medicare level 2 decision time | within 60 days | Original Medicare | G6 | |
| D34 | Number of Medicare appeal levels | 5 | Medicare | G6 | "There are 5 levels of appeal." Levels 3-5 dollar thresholds not verified today; left off the page. |
| D35 | Medicare Advantage level 1 (plan reconsideration) filing time | 65 days from the date on the denial notice | Medicare Advantage (Part C) | G8; G9 | G8: "65 days from the date on the initial denial notice" |
| D36 | Medicare Advantage plan decision times | pre-service 30 days; payment 60 days; Part B drugs 7 days; fast (expedited) 72 hours | Medicare Advantage | G8; G9 | G9: "72 hours for expedited pre-service benefit or Part B drug requests" |
| D37 | If the Medicare Advantage plan says no again, the case goes automatically to an Independent Review Entity (level 2) | automatic | Medicare Advantage | G8; G9 | G8: "your appeal is automatically sent to level 2" |
| D38 | Medicare help line | 1-800-MEDICARE (1-800-633-4227); TTY 1-877-486-2048 | Medicare | G6; G8 | |
| D39 | SHIP: free, unbiased Medicare counseling, including help with appeals | no charge; phone 1-877-839-2675; locator on shiphelp.org | Medicare | G11; G12 | G11: "There is no charge to consumers for this assistance." "Contact your SHIP for assistance with appeals." |
| D40 | Part D (drug) appeals | not detailed on the page | Medicare Part D | | Not verified today; page sends drug denials to 1-800-MEDICARE or SHIP |

## D. Medicaid

| id | Claim | Figure | Applies to | Source | Quote / note |
|---|---|---|---|---|---|
| D50 | Medicaid managed care plan appeal filing time | 60 calendar days from the date on the denial notice | Medicaid managed care (MCO, PIHP, PAHP) | R3 (c)(2)(ii) | "60 calendar days from the date on the adverse benefit determination notice" |
| D51 | Managed care plans may have only one level of appeal; after it, the person may ask for a state fair hearing | | Medicaid managed care | R3 (b), (c)(1)(i) | "may have only one level of appeal for enrollees" |
| D52 | Appeal may be requested orally or in writing | | Medicaid managed care | R3 (c)(3)(ii) | "either orally or in writing" |
| D53 | State fair hearing request time | set by the state; a reasonable time not to exceed 90 days from the date the notice is mailed | Medicaid (state fair hearing) | R4 (d) | "not to exceed 90 days from the date that notice of action is mailed". The page gives no single number: the state sets it and it may be shorter. |
| D54 | State Medicaid agency contacts | listed per state | Medicaid | G10 | Page links G10 rather than listing numbers |

## E. Free help (other)

| id | Claim | Figure | Applies to | Source | Quote / note |
|---|---|---|---|---|---|
| D60 | U.S. Department of Labor, EBSA benefits advisors | 1-866-444-3272 | Job-based plans (private employers) | G4; G5 | G5 lists "(866) 444-3272" with Benefits Advisors for health plan questions |
| D61 | Consumer Assistance Programs help consumers file complaints and appeals against health plans (where a state has one) | | State programs | G13; D15 | G13: "Helping consumers file complaints and appeals against health plans". CMS's per-state CAP listing (cms.gov/cciio/Resources/consumer-assistance-grants, last modified 2024-09-10) could not be read reliably, so the page does not list states; it points to the contact the denial letter must include (D15). |

## F. Why bother: statistics

| id | Claim | Figure | Plan year | Source | Quote / note |
|---|---|---|---|---|---|
| D70 | HealthCare.gov insurers denied in-network claims | 19% | 2024 | K1 | "denied 19% of in-network claims in 2024" |
| D71 | Range of in-network denial rates across insurers | 3% to 36% | 2024 | K1 | "ranged from 3% to 36%" |
| D72 | Share of denied claims appealed | fewer than 1% | 2024 | K1 | "fewer than 1% of denied claims were appealed" (262,982 internal appeals of about 85 million in-network denials) |
| D73 | Share of internal appeals where the insurer upheld its denial | 66% | 2024 | K1 | "66% of appeals were upheld" (so about a third were not upheld; KFF does not state an overturn rate, and the page does not compute one in KFF's name) |
| D74 | Claims received | about 496 million (about 451 million in-network) | 2024 | K1 | |
| D75 | Medicare Advantage prior authorization determinations | nearly 53 million (52.8 million) | 2024 | K2 | |
| D76 | Share fully or partially denied | 7.7% (4.1 million) | 2024 | K2 | "denied in full or in part" |
| D77 | Share of denied requests appealed | 11.5% | 2024 | K2 | "Just 11.5% of denied requests were appealed." |
| D78 | Share of appeals that overturned the denial (fully or partially) | 80.7% | 2024 | K2 | "80.7% of appeals overturned the initial denial" |

## G. What is published about denials by claim cost (for the calculator)

| id | Claim | Source | Note |
|---|---|---|---|
| D80 | CMS's Marketplace transparency data report denials as counts of claims (received, denied, resubmitted, denial reasons, appeals), with no dollar amounts or cost groups | G14 | Every claims field is a "Number of ..." count |
| D81 | KFF's 2024 Marketplace analysis counts claims; insurers do not report what services were denied | K1 | "Insurers do not report what types of services were denied" |
| D82 | The federal prior authorization reporting rule (CMS-0057-F) requires percentages approved and denied, aggregated for all items and services; counts optional | K3 | "Insurers are not required to report the number ... (only percentages)" |
| D83 | Massachusetts' 2024 state analysis of denials uses claim-line counts and says it does not show patient financial impact | M1 | "The denominator is total reported claim lines (both paid and denied)." |
| D84 | Conclusion used on the page | G14, K1, K3, M1 | "In the federal and state sources we checked, denials are reported as counts or percentages. We did not find any insurer or government dataset that reports denial rates by claim cost." Scope: we did not survey every insurer's own publications. |

## Could not open or verify (left off the page)

- 45 CFR 147.136 current text at law.cornell.edu: the permission request timed out. The 2020 annual edition on GovInfo (R5) was read instead; the provisions cited (b)(3)(i), (b)(3)(ii)(C), (d)(2)(i) match the current DOL twin (R2) and CMS's August 2026 overview (G3).
- NAIC state insurance department map (content.naic.org/state-insurance-departments): permission request timed out. The page tells people to look up their state's department of insurance without a link.
- Medicare levels 3 to 5 amount-in-controversy thresholds for 2026: not checked; left off.
- Medicare Part D deadlines: not checked; left off.
- HealthCare.gov Marketplace call center number: not used (it does not handle insurer claim appeals).
- A list of which states currently have a Consumer Assistance Program: the CMS listing could not be read reliably; left off.