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.

Fastest Path To Payment

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 requires a 30-business-day Open Negotiation period where providers and insurers must attempt to settle payment disputes. This is not optional, it is mandatory.

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
Not something you can skip

Start Mandatory Open Negotiation

77-80% provider win rate in IDR

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 or 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 or patient, or an authorized representative

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

How to know: 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 Is Not	Who Starts It
Open Negotiation/IDR	Mandatory pre-arbitration for surprise bills under No Surprises Act	Optional process; in-network disputes	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 or employee, or authorized representative

Still Not Sure Which Applies to You?

We are here to help. Get started and we will guide you through the right process.

Get Started