ERISA self-funded plan appeal deadlines (2026, verified)
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.
Per Appealant’s verified payer-deadline database, every value on this page is quoted verbatim from a primary source — the governing federal or California regulation — with the source linked and its effective date shown (sources re-retrieved 2026-07-04).
Calendar, business, and working days are not interchangeable, and month-based windows are never converted to day counts. Source documents were re-retrieved and verified 2026-07-04.
What is the appeal level 1 filing deadline for ERISA self-funded employer plans?
180 calendar days, counted from receipt of adverse benefit determination notice. Verified verbatim by Appealant from the primary source — 29 CFR § 2560.503-1(h)(3)(i), effective 2002-01-01 — most recently re-retrieved 2026-07-04.
Full rules table, with verbatim sources
| Rule | Value | Clock starts | Applies to | Verbatim source text |
|---|---|---|---|---|
| Appeal level 1 filing | 180 calendar days | receipt of adverse benefit determination notice | Provider deadline | (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 29 CFR § 2560.503-1(h)(3)(i) (effective 2002-01-01) |
| Full and fair review independent reviewer | — (procedural rule, no numeric deadline) | — | Payer / reviewer clock | (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 29 CFR § 2560.503-1(h)(3)(ii) (effective 2002-01-01) |
| Medical judgment consultation | — (procedural rule, no numeric deadline) | — | Payer / reviewer clock | (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 29 CFR § 2560.503-1(h)(3)(iii) (effective 2002-01-01) |
| Deemed exhaustion | — (procedural rule, no numeric deadline) | — | Payer / reviewer clock | (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. 29 CFR § 2560.503-1(l)(1) (effective 2002-01-01) |
| Urgent expedited review | — (procedural rule, no numeric deadline) | — | Payer / reviewer clock | (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. 29 CFR § 2560.503-1(h)(3)(vi) (effective 2002-01-01) |
| External review request window | Confirm in your provider manual — this rule has not been verified against a primary source and its value is not asserted here. | 29 CFR § 2590.715-2719(d) (federal external review) (no stated effective date) | ||