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ACA / Marketplace Appeals Resource Guide
The Affordable Care Act gives Marketplace and individual-market members the right to appeal. Knowing which appeal you need, and the deadlines that come with it, is the critical first step.
Written for providers, billers, and patients.
The Affordable Care Act established rights and protections for health insurance consumers, including coverage standards and appeal processes. These apply to Marketplace plans (Healthcare.gov or state exchanges) and to individual-market plans that comply with ACA requirements.
If your coverage comes through a private-sector employer instead, your appeal is governed by ERISA, not the ACA. See the ERISA appeals guide for that path.
Most important deadline
180 days from the denial to file your internal appeal.
Miss the window and you can lose your right to appeal entirely.
- Internal appeal: file within
- 180 days of the denial
- Plan responds (post-service)
- 60 days · 72 hrs if urgent
- External review: request within
- 60 days of final denial
- External review decision
- 45 days · 72 hrs if urgent
Step one
Confirm you qualify for an ACA appeal
The appeal path depends entirely on how your plan is regulated. Use this quick check first. If your plan is actually employer-sponsored, the ERISA appeals guide applies instead.
You qualify for ACA appeals if…
- Individuals with Marketplace / Exchange plans (Healthcare.gov)
- Small businesses with SHOP plans
- Individual market plans purchased outside the Marketplace (ACA-compliant)
You do NOT qualify if…
- Employer-sponsored plans (use ERISA appeals)
- Grandfathered plans (pre-ACA plans)
- Medicare beneficiaries
- Short-term limited duration insurance
The three categories
Types of ACA appeals
ACA appeals fall into three categories. Identify which one fits your situation, because each follows a different process and timeline.
Coverage denial appeals
When insurance denies medical care or treatment.
Common denial reasons
- Pre-authorization denied
- Medical necessity determination
- Experimental / investigational treatment
- Out-of-network claims (HMO plans)
- Prescription drug denials
- Service limitation exceeded
Eligibility & subsidy appeals
When the Marketplace denies eligibility for coverage, subsidies, or special enrollment.
Common issues
- Subsidy (premium tax credit / cost-sharing reduction) denial or wrong amount
- Medicaid eligibility determination
- Special Enrollment Period denial
- Income verification issues
- Household size disputes
Enrollment appeals
When there are issues with enrollment, plan assignment, or effective dates.
Category A
Coverage denial appeal process
You file an internal appeal first. If it is denied, you can request an independent external review.
Deadlines are everything
Deadline for the plan's decision
- Urgent pre-service
- 72 hours
- Pre-service (non-urgent)
- 30 days
- Post-service
- 60 days
Internal appeal steps
- 1 Review the denial letter carefully and note the specific reason codes.
- 2 Contact the insurance company to discuss the denial.
- 3 Request a detailed explanation and the relevant policy sections.
- 4 Gather supporting evidence (medical records, doctor's letter, clinical guidelines).
- 5 Submit a written appeal that addresses each denial reason.
- 6 Follow up to confirm receipt and track status.
External review
- Request within
- 60 days of final internal denial
- Decision within
- 45 days · 72 hours if urgent
- 1 Complete the external review request form.
- 2 Submit it to the state external review agency or your health plan.
- 3 Provide all documentation from the internal appeal.
- 4 Add any new evidence.
The external reviewer's decision is binding.
Category B
Eligibility & subsidy appeals
These appeals go to the Marketplace itself, not your insurer, and they follow a two-level path.
First level: appeal to the Marketplace
- Must file within 90 days of the eligibility notice.
- Decision typically within 90 days.
Second level: Federal Marketplace Appeals Center
- Applies if the Marketplace upholds an unfavorable decision.
- Request a hearing with an administrative law judge.
How to file an eligibility appeal
- Online
- Through your Healthcare.gov account
- Phone
- 1-800-318-2596 (TTY: 1-855-889-4325)
- Health Insurance Marketplace, Dept of Health & Human Services, 465 Industrial Blvd, London, KY 40750-0001
- Fax
- 1-877-369-0130
Build your file
Documentation checklists
Gather these documents before you file. A complete, well-organized file is what overturns denials.
For medical claim appeals
- Denial letter with specific reasons
- Summary of Benefits and Coverage (SBC)
- Complete medical records
- Letters from providers
- Clinical evidence and guidelines
- Prior authorization request history
For eligibility / subsidy appeals
- Eligibility determination notice
- Most recent tax return
- Recent pay stubs (2-3 months)
- W-2 forms
- Proof of household members
- Bank statements (if self-employed)
Reference & tools
Key ACA resources
Marketplace Call Center
Phone: 1-800-318-2596 | TTY: 1-855-889-4325
Call for assistance with appeals, eligibility questions, and enrollment issues.
Keep reading
Related guides
ERISA (employer plan) appeals
For coverage through a private-sector employer, which is not ACA.
ReadNo Surprises Act appeals
Protection against surprise out-of-network bills.
ReadWhich appeal do I need?
Compare appeal types side by side.
ReadAppeal deadlines
Every filing window, in one reference.
ReadAppeals glossary
Plain-English definitions of ERISA, IDR, QPA, SPD, and the rest.
ReadDisclaimer
This guide is for informational purposes only and does not constitute legal or medical advice. Appeal It Now provides administrative support and appeal preparation services only; we are not a law firm. Please consult a qualified professional for advice specific to your situation.
Version 1.0 · Updated May 2026