Self-funded employer plans are governed by the federal ERISA claims-procedure regulation, not state insurance law. The plan must give claimants at least a 180-day window after an adverse benefit determination to appeal; plan documents may allow more. The rules below are federal minimums that apply nationwide.
Day types are not interchangeable: calendar, business, and month windows each count differently, and month windows are never converted to days. Every value below is quoted from its primary source.
Deadlines you must hit
Appeal level 1 filing
180 calendar daysClock starts: receipt of adverse benefit determination notice
(h)(3)(i) Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination
Source: 29 CFR § 2560.503-1(h)(3)(i)
External review request window
4 monthsClock starts: receipt of adverse or final internal adverse benefit determination notice
A group health plan or health insurance issuer must allow a claimant to file a request for an external review with the plan or issuer if the request is filed within four months after the date of receipt of a notice of an adverse benefit determination or final internal adverse benefit determination.
Source: 29 CFR § 2590.715-2719(d)(1)(i) (federal external review)
Payer response clocks
Full and fair review independent reviewer
Procedural rule(h)(3)(ii) Provide for a review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the plan who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual
Source: 29 CFR § 2560.503-1(h)(3)(ii)
Medical judgment consultation
Procedural rule(h)(3)(iii) Provide that, in deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment
Source: 29 CFR § 2560.503-1(h)(3)(iii)
Deemed exhaustion
Procedural rule(l)(1) In the case of the failure of a plan to establish or follow claims procedures consistent with the requirements of this section, a claimant shall be deemed to have exhausted the administrative remedies available under the plan and shall be entitled to pursue any available remedies under section 502(a) of the Act on the basis that the plan has failed to provide a reasonable claims procedure that would yield a decision on the merits of the claim.
Source: 29 CFR § 2560.503-1(l)(1)
Urgent expedited review
Procedural rule(h)(3)(vi) Provide, in the case of a claim involving urgent care, for an expedited review process pursuant to which (A) A request for an expedited appeal of an adverse benefit determination may be submitted orally or in writing by the claimant; and (B) All necessary information, including the plan's benefit determination on review, shall be transmitted between the plan and the claimant by telephone, facsimile, or other available similarly expeditious method.
Source: 29 CFR § 2560.503-1(h)(3)(vi)
Reference information for provider billing teams, not legal advice. Windows depend on the plan's regulator and product, so confirm against your contracted provider manual. Sources retrieved 2026-07-04.