Appeal Types

Which Appeal Process Do You Need?

Not all insurance appeals are the same. Understanding which type of appeal applies to your situation is the crucial first step. Each follows different rules, timelines, and federal regulations.

Clear Guidance, No Confusion

Insurance appeals can feel overwhelming, but they do not have to be. Here is what each appeal type is and is not, so you can identify your path forward with confidence.

Open Negotiation & IDR

For Out-of-Network Surprise Bills (No Surprises Act)

Time-Sensitive: 30-Day Deadline

Open Negotiation must begin within 30 business days of receiving the initial payment or denial from insurance.

WHAT IT IS

The federally mandated first step before Independent Dispute Resolution (IDR) for out-of-network surprise medical bills covered under the No Surprises Act.

Federal law sets a 30-business-day Open Negotiation period where providers and insurers attempt to settle the payment dispute. Completing it is the required first step before either side can take the dispute to IDR arbitration.

WHAT IT IS NOT

✕NOT for in-network claims or denials
✕NOT for elective out-of-network services
✕NOT a patient-initiated process
✕NOT a traditional insurance appeal

Start Open Negotiation →

Who initiates:Healthcare providers (or their representatives)

Typical situations:Emergency room bills, out-of-network anesthesiologist charges, surprise bills from out-of-network providers at in-network facilities

Patient Appeal

For Coverage Denials Under Your Health Plan

✓ WHAT IT IS

Your legal right to challenge an insurance company's decision to deny coverage, reduce payment, or refuse pre-authorization for medical treatment. This applies to claims under your personal or employer-sponsored health insurance plan when seeking coverage for services, prescriptions, or treatments that were denied.

✕ WHAT IT IS NOT

✕NOT for out-of-network surprise bills (that's Open Negotiation/IDR)
✕NOT a negotiation between provider and insurance company
✕NOT for billing disputes where coverage was approved but payment amount is contested
✕NOT handled by your provider (though they can help with documentation)

Who initiates:You, the patient

Typical situations:Pre-authorization denials, experimental treatment denials, medical necessity denials, out-of-network coverage disputes

Get Help with Patient Appeals →

ERISA Appeal

For Employer-Sponsored, Self-Funded Health Plans

✓ WHAT IT IS

A federally regulated appeal process specifically for employer-sponsored, self-funded health insurance plans governed by the Employee Retirement Income Security Act (ERISA). These appeals follow strict federal procedural rules that differ from state-regulated insurance plans. You must exhaust all internal appeal levels before pursuing legal action in federal court.

✕ WHAT IT IS NOT

✕NOT for individual/marketplace insurance plans (those follow state laws)
✕NOT for Medicare or Medicaid
✕NOT for government employee health plans (federal, state, local)
✕NOT for church plans (unless they opted in)
✕NOT subject to state insurance laws or state external review
✕NOT the same as a standard insurance appeal

Who initiates:Employee/patient or authorized representative

Typical situations:Denied claims, benefit disputes, coverage terminations, plan interpretation disagreements

Tip: Your insurance documents will include an "ERISA Summary Plan Description".

Get Help with ERISA Appeals →

Quick Comparison

See the key differences at a glance.

Appeal Type	What It IS	What It's NOT	Who Starts It
Open Negotiation/IDR	Open negotiation, then IDR arbitration, for surprise bills under the No Surprises Act	In-network disputes; patient appeals	Provider or Authorized Representative
Patient Appeal	Challenge to coverage denials for medical treatment	Payment amount negotiation; surprise billing	Patient
ERISA Appeal	Federal appeals for employer-sponsored self-funded plans	State-regulated insurance; government plans	Patient/Employee or Authorized Representative
ACA / Marketplace Appeal	Internal appeal plus independent external review for individual and marketplace plans	Employer self-funded (ERISA) plans; Medicare or Medicaid	Patient
Out-of-Network Underpayment	Recover a repriced or underpaid out-of-network claim	A full coverage denial; surprise bills (No Surprises Act)	Patient or Provider

Still Not Sure Which Applies to You?

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