Coverage type · Job-based plan
Employer plan the employer funds itself (self-funded)
Your employer pays your claims from its own money, often with an insurance company handling the paperwork. Federal law governs the plan, so the Department of Labor, not your state, is the agency to call.
On this page 7
- Who has this
- People who get health coverage through a private employer or union that pays claims itself. The name on your card may still be a well-known insurance company that only processes the claims.
- Who regulates it
- Department of Labor, Employee Benefits Security Administration (EBSA), help line 1-866-444-3272. Your state insurance department generally cannot apply state insurance law to this plan.
- Can your state help?
- No. Federal law (the Employee Retirement Income Security Act, ERISA) overrides state law that relates to employer plans, and a self-funded plan is not treated as an insurer, so state appeal and external review laws generally cannot be applied to it. Your state insurance department usually cannot decide your appeal or order the plan to pay. A state Consumer Assistance Program may still answer questions or point you to the Department of Labor. Find your state.
How to tell this is your coverage
- Read your summary plan description (SPD, the booklet that explains your plan). It must name any insurance company involved and say whether and to what extent benefits are guaranteed under an insurance contract, and what the insurer does, such as paying claims. If the insurer only pays claims and the employer carries the cost, the plan is self-funded.
- Ask your human resources department or plan administrator two plain questions: Is our plan self-funded or fully insured? Is the company on my card the insurer, or only the claims administrator?
- Ask for the plan documents in writing. The plan administrator must send the latest summary plan description on written request, and may charge no more than 25 cents a page. Keep a copy of your request and the date you sent it.
- Search the Department of Labor's public Form 5500 database (the plan's annual report) for your employer's health plan. Treat it as a clue only: a plan with fewer than 100 participants may not have to file, so finding nothing proves nothing. We have not confirmed how insurance details appear on the form.
- Look at the denial notice. A notice that tells you about the right to sue under the Employee Retirement Income Security Act (ERISA) shows the plan is a private employer plan, but it does not say whether the plan is self-funded or insured.
The appeal steps, in order
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First appeal to the plan
Official name: Internal appeal (an appeal of an adverse benefit determination)
- Who decides
- The plan or its claims administrator. The reviewer must be someone who did not make the first decision and does not report to that person, and must not defer to it. If the denial rests on a medical judgment, the reviewer must consult a health professional who was not involved in the first decision.
- Your deadline
- At least 180 days after you receive the denial notice. Your plan may allow more time, never less. Check the date on your notice, which controls.
- Their deadline
- Urgent care: as soon as possible and no later than 72 hours after the plan receives your appeal. Care you need approved first: 30 days (15 days at each level if your plan has two levels). Care you already received: 60 days (30 days at each level if two levels). The federal rule gives group health plans no extension on appeal, other than a meeting-based schedule for certain multiemployer (union) plan boards. Your plan documents say which applies. Check the date on your notice, which controls.
- What to send
- A written appeal that names the claim, the denial and why you disagree, plus records, your doctor's letter and any comments you want considered. The reviewer must consider everything you send, even things the first decision never saw. There is no fee to appeal. Ask for your claim file first; the plan must give it to you free.
- If you lose, or hear nothing
- If the plan upholds the denial and has a second appeal level, file it. If it has none, or you finish the last level, go to independent external review. A grandfathered plan (in place on 23 March 2010 and not changed in disqualifying ways) is exempt from general external review except for surprise-billing denials; see the page for grandfathered plans.
- The rule
- 29 CFR 2560.503-1(h) and (i), claims procedure for employee benefit plans
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Second appeal to the plan (only if your plan has one)
Official name: Second-level internal appeal
- Who decides
- The plan. A group health plan may not require more than two appeals before you can sue.
- Your deadline
- Set by your plan documents and stated in the first appeal decision. It is not a fresh 180 days. Check the date on your notice, which controls.
- Their deadline
- Half the usual time at each level: 15 days before care and 30 days after care for each level if your plan has two levels. If urgent, no later than 72 hours. Check the date on your notice, which controls.
- What to send
- A new letter that answers the reasons in the first appeal decision, with any new records or doctor's statement. Ask for the documents the plan relied on in the first appeal.
- If you lose, or hear nothing
- If the plan upholds the denial again, request external review. The four-month window for external review starts from the final internal denial.
- The rule
- 29 CFR 2560.503-1(c) and (i)(2), number of appeal levels and decision times
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Independent external review through the federal process
Official name: Federal external review by an accredited independent review organization (IRO)
- Who decides
- An independent review organization (IRO) that your plan contracts with. The plan must contract with at least three accredited IROs and rotate cases among them, and the IRO may not be paid by how often it upholds denials. It looks at your claim fresh and is not bound by the plan's earlier decisions. Your state's external review process does not apply to a self-funded plan unless your state allows it and the plan chose to join.
- Your deadline
- At least 4 months after you receive the denial notice (the final internal denial, if you appealed first). If there is no matching date, the deadline is the first day of the fifth month. A deadline on a weekend or federal holiday moves to the next business day. Check the date on your notice, which controls.
- Their deadline
- The plan checks whether your request qualifies within 5 business days and tells you within 1 more business day. A standard decision is due within 45 days after the IRO receives your request. An urgent decision is due as fast as your medical situation requires and no later than 72 hours.
- What to send
- Follow the instructions in your final denial notice for where to send the request. Include the denial notice, your records and your doctor's letter. You can send the IRO more information for at least 10 business days after its notice. Only denials that involve medical judgment, the No Surprises Act protections, or a cancellation of coverage (rescission) qualify; a denial because you are not eligible for the plan does not. If the request is ineligible, the notice must give the Department of Labor's contact details.
- Form
- HealthCare.gov, how external review works
- If you lose, or hear nothing
- If the IRO overturns the denial, the plan must provide coverage or payment immediately, even if it plans to go to court. If the IRO upholds the denial or says your case does not qualify, ask the Department of Labor for help and talk to a lawyer about a lawsuit.
- The rule
- 29 CFR 2590.715-2719(d), federal external review process
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Help from the Department of Labor
Official name: Employee Benefits Security Administration (EBSA) benefits advisors
- Who decides
- An advisor at the Department of Labor's Employee Benefits Security Administration answers your question or takes your complaint. We could not confirm that the agency will overturn a denial for you, and asking for its help does not replace an appeal.
- Your deadline
- We could not confirm a deadline for this step. Ask early, and keep every appeal and external review deadline running. Check the date on your notice, which controls.
- Their deadline
- We could not confirm a response time, so ask when you contact the agency.
- What to send
- Call 1-866-444-3272 or use the online request form. Have ready your employer or union name, your plan name, the denial notice and the dates of every appeal you filed.
- Form
- Ask EBSA, request help from a benefits advisor
- If you lose, or hear nothing
- Use the advisor's answer to decide on your next step. A plan that breaks the claims rules may lose the protection of its own appeal process, which can open the door to court.
- The rule
- Department of Labor, Filing a Claim for Your Health Benefits
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Lawsuit in court
Official name: Civil action under section 502(a) of the Employee Retirement Income Security Act (ERISA)
- Who decides
- A federal or state judge. The court reviews the denial fresh unless the plan gives its administrator discretion to decide eligibility or interpret the plan; if it does, the court gives the decision more deference. The court may award reasonable attorney's fees and costs to either side.
- Your deadline
- ERISA sets no deadline for a benefit lawsuit, but your plan document may set its own, even one that starts running before the appeals end, if it is reasonable. Read the plan document now. Courts generally expect you to finish the plan's appeals first. Check the date on your notice, which controls.
- Their deadline
- Set by the court.
- What to send
- A lawyer files the suit. Put your records, your doctor's letter and your arguments in the appeal itself; do not count on adding them later in court.
- If you lose, or hear nothing
- State-law claims for damages over a benefit denial are generally preempted (overridden) for these plans. The suit is for the benefit, other fair relief and possibly fees.
- The rule
- ERISA section 502, 29 U.S.C. 1132
If waiting could harm your health
If waiting could seriously harm your health, ask for an urgent appeal. The plan must decide within 72 hours, and a doctor who knows your condition can act for you in an urgent case. If a doctor who knows your condition says the claim is urgent, the plan must treat it as urgent. You can ask for an urgent independent review at the same time as the urgent appeal. Phone is allowed for an urgent appeal.
Free help for this coverage
- Department of Labor benefits advisors
Free help by phone at 1-866-444-3272 or through an online form. This is the federal agency that oversees private employer health plans, including self-funded plans that your state cannot help with.
- Your state Consumer Assistance Program
Can answer questions and help with appeals for some coverage. The list kept by the Centers for Medicare & Medicaid Services (CMS) sends people with self-funded employer coverage to the Department of Labor. The CMS page says no program receives federal grant money as of its September 2024 update, so confirm your state's listing is current.
- Patient Advocate Foundation case management
Free one-on-one help for patients who qualify, by phone at 1-800-532-5274, Monday to Friday, 8:30 a.m. to 5:00 p.m. Eastern (hours as listed in November 2026). Case managers work on appeals, bills and coverage. It has limits on how many people it can take each day.
- Free legal aid
Legal aid offices and state bar associations can point you to a lawyer. Ask for someone who handles employer health plan benefit claims.
Who this covers
This page is for you if your employer or union pays your medical claims itself instead of buying an insurance policy. Many large employers do this. An insurance company often runs the plan for them, so the card and the letters can carry the insurer’s name even though the employer carries the cost.
How to tell this is your coverage
The steps in the list above come down to one question: who bears the cost of the claims? The summary plan description and your human resources department can answer it. Ask in writing so you have a record. If the answers conflict, believe the plan document.
What does not apply to you
Your state insurance department usually cannot decide your appeal, and your state’s external review process does not apply unless your state allows it and the plan chose to join. State laws that protect people with insured plans generally do not reach this plan. That is not a loss of appeal rights: federal law gives you its own appeal steps, listed above.
Where people go wrong
- Calling the state insurance department first and losing weeks. Call the Department of Labor instead.
- Treating a call to a regulator as an appeal. It does not stop your appeal deadline.
- Waiting on the independent review deadline. It is at least four months, not 180 days.
- Putting evidence off until a lawsuit. Do not count on adding it later in court; put it in the appeal.
Sources
- 29 CFR 2560.503-1, claims procedure
- 29 CFR 2590.715-2719, internal claims and appeals and external review
- 29 CFR 2520.102-3, contents of the summary plan description
- ERISA section 514, 29 U.S.C. 1144
- ERISA section 502, 29 U.S.C. 1132
- ERISA section 104(b)(4), 29 U.S.C. 1024
- Filing a Claim for Your Health Benefits
- Search Form 5500 filings
- Heimeshoff v. Hartford Life and Accident Insurance Co., 571 U.S. 99 (2013)
- Ask EBSA, request help from a benefits advisor
- Consumer Assistance Program
- HealthCare.gov, external review
- Patient Advocate Foundation case management