Deadlines and appeals
Last reviewed · Educational use only
Missed deadlines turn payable claims into write-offs. The limits differ by payer type, and the contract or plan document controls for commercial plans.
Timely filing
| Payer | Initial claim deadline |
|---|---|
| Original Medicare | 12 months (one calendar year) from the date of service |
| Medicare Advantage | Set by the plan or contract; often 90 days to 1 year for in-network providers |
| Medicaid / CHIP | Set by the state, commonly 90 days to 12 months |
| Commercial, in network | Per the provider contract, commonly 90 to 180 days |
| Commercial, out of network | Per the plan document, often 12 to 15 months |
| TRICARE | 1 year from the date of service |
| Secondary claims | Usually measured from the primary payer's remittance date; check each plan |
Keep proof of timely filing: clearinghouse acceptance reports (999 and 277CA) with dates, not just your practice-management send date. A rejected claim was never received, so the clock kept running.
Appeal levels
Group health plans and individual insurance (ACA / ERISA)
| Step | Deadline to file | Plan's decision time |
|---|---|---|
| Internal appeal | At least 180 days from the denial notice | Urgent care: 72 hours · Pre-service: 30 days · Post-service: 60 days |
| External review by an independent review organization | 4 months after the final internal denial (federal process; state processes vary) | Standard: 45 days · Expedited: 72 hours |
| ERISA lawsuit (self-funded and other employer plans) | After internal appeals are exhausted; plan may set a limit | Court review, usually of the plan's record |
Some group plans have two internal levels; the total time limits still apply. Grandfathered plans are not required to offer external review.
Original Medicare (Parts A and B)
| Level | Who decides | Deadline to file |
|---|---|---|
| 1. Redetermination | The Medicare Administrative Contractor (MAC) | 120 days from receiving the initial determination |
| 2. Reconsideration | Qualified Independent Contractor (QIC) | 180 days from the redetermination |
| 3. Hearing | Administrative Law Judge (OMHA), if the amount in controversy is met | 60 days |
| 4. Review | Medicare Appeals Council | 60 days |
| 5. Judicial review | Federal district court, if the amount in controversy is met | 60 days |
Medicare Advantage plans start with a plan-level reconsideration (65 days from the denial notice for enrollees; non-contracted provider rules are in the plan's notice), then automatic review by the Part C independent review entity if the plan upholds a denial; the later levels match Original Medicare. Amounts in controversy are adjusted each year.
Writing an appeal that works
- Quote the denial: claim number, date of service, code(s), and the CARC/RARC.
- Answer the reason given, point by point, against the plan's own medical policy or contract language.
- Attach the records that prove it: clinical notes, test results, the authorization, the corrected claim, the reference number from verification.
- Ask for a specific result ("reprocess at the in-network allowed amount", "overturn and pay as billed").
- Calendar the plan's response deadline and the next level's filing deadline the day you send it.
You have the right to appeal your own denials, and to ask for the plan's claim file and the medical policy used. Your provider's office can often help; for urgent care, ask for an expedited appeal. State insurance departments and consumer assistance programs help with fully insured plans; the Department of Labor helps with employer plans.