Resource Aid Center

6 min read · Last updated July 29, 2026

In this article

• Two clocks started the day that letter was dated
• The first 72 hours
• The full appeal calendar
• Work the hospital side at the same time
• The mistakes that end appeals early
• What to do at 30, 60, and 90 days
• FAQ

Dana’s letter arrived eleven days after a four-night hospital stay. Her insurer had decided the admission was not medically necessary, which meant the $28,400 was hers. She put the letter in a drawer for six weeks because she did not know what else to do with it. Those six weeks came out of a window she did not know she had.

Two clocks started the day that letter was dated

Federal claims rules set a floor your plan cannot go below. The first floor is your filing deadline. A group health plan’s procedures must “provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination” (29 CFR 2560.503-1). An adverse benefit determination is the formal name for the denial you are holding.

The second floor comes after that. If the plan denies your internal appeal, you can take the claim to an external review, where an independent reviewer who does not work for your insurer looks at it and can overturn the decision. The rules require at least four months after the final denial to request one (29 CFR 2590.715-2719, and HealthCare.gov’s external review page).

Together that is most of a year of process. Almost all of it is lost by people who assume the letter is final.

The first 72 hours

Three things, in this order.

Find the reason. Every denial names one: not medically necessary, out of network, no prior authorization, coding error. The reason determines your argument, and a surprising share of denials are administrative rather than clinical.

Ask for the file, in writing. You are entitled to the documents the plan relied on, free of charge. Request the full claim file and the specific plan language behind the denial, by a method that produces a receipt.

Call your doctor’s office before you write anything. If the denial says the care was not medically necessary, the strongest document in your appeal is a letter from the physician who ordered it. Ask for a letter of medical necessity by name.

The full appeal calendar

Step	Your deadline	Their deadline	Rule
File the internal appeal	At least 180 days from the denial notice	Not applicable	29 CFR 2560.503-1(h)(3)
Decision on an urgent care claim	Not applicable	72 hours	29 CFR 2560.503-1(f)(2)
Appeal decision, care not yet received	Not applicable	30 days on a one-level appeal	29 CFR 2560.503-1(i)(2)
Appeal decision, care already received	Not applicable	60 days on a one-level appeal	29 CFR 2560.503-1(i)(2)
Request external review	At least four months from the final denial	Not applicable	29 CFR 2590.715-2719
Nonprofit hospital pause on aggressive collections	Not applicable	At least 120 days from your first bill after discharge	26 CFR 1.501(r)-6
Apply for hospital financial assistance	At least 240 days from your first bill after discharge	Not applicable	26 CFR 1.501(r)-6

Put real dates on it. Dana’s denial is dated September 3, so her internal appeal is due by roughly March 2. Because her care was already received, the plan owes her a decision about 60 days after she files. If she files in October and loses in December, her external review request runs into roughly April. The bill she was told was final in September is still contestable seven months later.

That urgent-care row in the table above is its own situation, not a smaller version of the standard appeal. If you are disputing coverage for care that is already underway, such as a rehab stay the insurer never signed off on, the 72-hour appeal clock and the noon filing deadline that actually governs it are different from the timelines in this table, and missing the narrower window can mean losing the protection against being billed while the review is pending.

Work the hospital side at the same time

This is the part almost nobody is told. If you were treated at a nonprofit hospital, and most US hospitals are, federal tax rules require it to maintain a financial assistance policy, often called charity care, with hard timeframes around collections.

Before a hospital takes what the rules call an extraordinary collection action, meaning reporting you to a credit bureau, selling the debt, or suing, it must notify you about that policy and “refrain from initiating such ECAs … for at least 120 days from the date the hospital facility provides the first post-discharge billing statement” (26 CFR 1.501(r)-6). The same rule sets the application window at no earlier than “240 days after the date that the first post-discharge billing statement … was provided.”

Ask the billing office for the financial assistance application on the same call where you ask for an itemized bill. You are not choosing between the appeal and the application. Run both.

The mistakes that end appeals early

Calling instead of writing. Phone calls do not create a record the plan has to answer. Every substantive request goes in writing, even if you also call.

Missing the plan’s own shorter internal step. Some plans run two levels of internal appeal with tighter turnarounds. The 180 days is a federal floor for filing, but each level has its own instructions. Read the letter’s appeal section twice.

Paying the balance to stop the calls. Paying removes your leverage on both tracks at once. If collection pressure is the problem, that is what the 120-day rule is for. Say the words financial assistance application on the call.

Treating an itemized bill as optional. Ask for the itemized bill, not the summary. Duplicate charges and services never received are common enough that reading it line by line is worth an evening.

For the broader sequence after an emergency, see the 30 days after a medical emergency. If the denial follows a new diagnosis and your job is also at risk, start with the first two weeks after a serious diagnosis.

What to do at 30, 60, and 90 days

By day 30: Internal appeal filed in writing with the letter of medical necessity attached. Itemized bill requested. Financial assistance application requested from the hospital.

By day 60: If your care was already delivered, the plan’s decision is due around now. If nothing has arrived, write again and reference your filing date. Submit the assistance application whether or not the appeal has resolved.

By day 90: If the internal appeal failed, file the external review request rather than letting the four months run down. If the hospital approved assistance, get the adjusted balance in writing before you pay.

Frequently asked questions

The letter says I have 60 days to appeal. Which number is right? Read the letter carefully, because plans sometimes state the deadline for one internal level rather than the overall filing window. Federal rules require group health plans to allow at least 180 days to appeal an adverse determination. If your plan’s letter says less than that, call and ask them to point to the plan language, and file early rather than testing it.

What is an external review, and does the insurer have to follow it? An external review is a decision by an independent reviewer outside your insurance company. If the reviewer overturns the denial, the plan is required to honor that outcome.

I was billed by a doctor I never chose during my hospital stay. Is that allowed? Federal surprise-billing protections limit what you can be charged for many out-of-network services received at an in-network facility. Start with the federal No Surprises Act materials and raise it with the hospital’s billing office in writing.

Does applying for hospital financial assistance hurt my appeal? No. They are separate processes run by two different organizations. The hospital decides what you owe it, and the insurer decides what it will pay.

What if the hospital is for profit? The 120-day and 240-day rules come from the tax rules for nonprofit hospitals, so they do not bind a for-profit facility. Most for-profit systems still run assistance and hardship programs. Ask for the policy in writing and get any discount confirmed in writing before you pay.