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ERISA Appeals Resource Guide

ERISA governs most employer-sponsored health plans. Confirming your plan is covered, and knowing the deadlines, is the critical first step in any appeal.

Written for providers, billers, and patients.

ERISA (the Employee Retirement Income Security Act of 1974) sets the rules for most employer-sponsored health plans in the United States, including your appeal rights, the timelines, and the procedures the plan must follow.

It also requires you to exhaust every internal appeal before you can pursue external review or file in federal court. That makes the deadlines below non-negotiable.

Most important deadline

180 days from the denial to file your first internal appeal.

Miss the window and you can lose your right to appeal entirely.

Level 1: file within
180 days of the denial
Level 1: plan responds
30 days · 72 hrs if urgent
External review: file within
4 months of final denial
Federal court: file within
≥ 1 year of final decision

Step one

Verify ERISA coverage

The appeal path depends entirely on how your plan is regulated. Use this quick check first. If it is not an ERISA plan, the ACA / Marketplace guide likely applies instead.

Your plan is ERISA if…

  • Health insurance through a private-sector employer
  • Employer has 2 or more employees
  • COBRA continuation coverage

It is probably not ERISA if…

  • Government (federal, state, or local) employee
  • Self-employed with no employees
  • Individual marketplace (ACA) plan
  • Medicare or Medicaid

Official federal resources

Department of Labor (EBSA) dol.gov The primary federal agency overseeing ERISA plans. ERISA Claims Regulations (29 CFR 2560.503-1) ecfr.gov Governs your appeal rights, timelines, and procedures.

The process

The 3-level ERISA appeal process

You generally move through these in order. Each level has its own filing window and response time.

Deadlines are everything

Missing a filing window almost always means losing your appeal rights, regardless of how strong your case is. Track every date and keep confirmation of every submission.
  1. 1

    First internal appeal

    You must file within
    180 days of the denial
    Plan must respond within
    30 calendar days (post-service) · 72 hours (urgent)
  2. 2

    Second internal appeal

    You must file within
    180 days of the Level 1 denial
    Plan must respond within
    30 calendar days
    • Check your SPD: some plans require two internal levels, others only one.
  3. 3

    External independent review

    You must file within
    4 months of the final internal denial
    Decision within
    45 days · 72 hours if urgent
    • Reviewed by an independent medical expert who is not affiliated with your insurer, who reviews the case de novo (from scratch).
    • The external reviewer’s decision is binding on the insurance company.
    • After a Level 3 denial you have at least 1 year from the final decision date to file an ERISA case in federal court (your SPD may allow longer).

Time-sensitive case? See the 72-hour urgent ERISA appeal process, which lets you file internal and external review simultaneously.

The evidence that wins

Clinical practice guidelines by specialty

Clinical practice guidelines are the gold standard for proving medical necessity: evidence-based recommendations that define the standard of care. Cite the guideline from the relevant specialty organization.

Reference & tools

Databases and resources to support your appeal

Keep reading

Related guides

72-hour urgent ERISA appeal

Expedite when waiting would seriously jeopardize your health.

Read

ACA / Marketplace appeals

For individual marketplace plans, which are not ERISA.

Read

Which appeal do I need?

Compare appeal types side by side.

Read

Appeal deadlines

Every filing window, in one reference.

Read

Appeals glossary

Plain-English definitions of ERISA, IDR, QPA, SPD, and the rest.

Read

Disclaimer

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

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