Behavioral-health appeal deadline calculator

How do I use the appeal deadline calculator?

Pick the plan type from the member ID card or the notice, say whether this is a first denial or the denial of an internal appeal, choose what was denied and how urgent it is, then enter the date on the notice. The dates appear at once, with the rule behind each one.

1. 01Find the plan type. Medicaid and Medicare Advantage plans say so on the card; an employer plan names the employer; a marketplace plan names the exchange. If you can't tell, choose Other or not sure and the calculator works to the shortest common window.
2. 02Choose the notice: the first denial (an adverse benefit or organization determination) or the plan's decision on your internal appeal. The second unlocks external review, a fair hearing or independent review.
3. 03Choose what was denied: a prior authorization, a concurrent review or continued stay, or a claim for care already given. This sets the plan's decision clock.
4. 04Mark it urgent only if waiting the standard time could seriously jeopardize the patient's life, health or ability to regain function. Under the ERISA rules, a physician with knowledge of the condition can make that call.
5. 05Enter the date on the notice. Add the date of service if you also want timely-filing reference dates.
6. 06Download the .ics file to put the deadline, with seven-day and one-day reminders, on your calendar. Then check every date against the notice.

What appeal deadlines apply to an employer (ERISA) health plan?

A group health plan must allow at least 180 days after you receive the denial notice to appeal. It must then decide an urgent appeal within 72 hours, a pre-service appeal within 30 days and a post-service appeal within 60 days of receiving it. These are calendar days, so weekends and holidays count.

The 180-day minimum is in 29 CFR 2560.503-1(h)(3)(i); the appeal clocks are in paragraph (i)(2). A plan with two appeal levels gets half the time for each level: 15 days per level for pre-service appeals and 30 days per level for post-service appeals. The clock starts when the appeal is filed, even if some information is still missing.

Concurrent review has its own protection. If a plan cuts short a course of treatment it already approved, that is an adverse benefit determination, and the plan must tell you early enough to appeal and get a decision before the cut takes effect. An urgent request to extend treatment, made at least 24 hours before the approved period ends, must be decided within 24 hours.

The first-decision clocks matter too: 72 hours for urgent claims, 15 days for pre-service claims and 30 days for post-service claims, each with one possible 15-day extension except urgent. If the plan missed them, say so in the appeal. When a plan fails to strictly follow the claims rules, the claimant can be treated as having exhausted internal appeals and go straight to external review, unless the slip was minor and harmless.

How is the four-month external review deadline counted?

Under the federal process you have four months after receiving the final internal denial. If that month has no matching date, the deadline is the first day of the fifth month, so a denial received October 30 runs to March 1. A Saturday, Sunday or federal holiday moves the deadline to the next business day.

The rule is in 29 CFR 2590.715-2719(d)(2)(i) and the identical 45 CFR 147.136(d)(2)(i). The calculator applies all three steps: four calendar months, the first-of-the-fifth-month fallback, and the next-business-day extension using the federal holiday calendar.

Once filed, the plan does a preliminary review within five business days and must tell you the result within one business day. The independent review organization (IRO) accepts additional information for ten business days after it notifies you, decides a standard request within 45 days, and decides an expedited request within 72 hours. In urgent cases you can ask for expedited external review at the same time as an expedited internal appeal.

Insured plans usually use the state's external review program, which must allow at least four months. HealthCare.gov says the HHS-administered process is free and state or contracted processes may charge up to $25. Grandfathered plans generally don't have to offer external review, except for surprise-billing claims.

What deadlines apply to a Medicaid managed care denial?

The enrollee has 60 calendar days from the date on the notice to appeal to the plan. The plan must decide within 30 calendar days, or 72 hours if expedited, with up to 14 more days in some cases. After an upheld appeal, the state fair hearing window is set by each state at 90 to 120 days.

The appeal window is in 42 CFR 438.402(c)(2)(ii) and the decision clocks in 438.408(b). A provider or authorized representative can appeal only where state law permits and with the enrollee's written consent. A provider can ask for, or support, an expedited appeal under 438.410.

To keep previously authorized services going during the appeal, the enrollee must file within 10 calendar days of the plan sending the notice, or by the date the change takes effect if that is later (438.420). That is the date that matters most for a continued-stay or step-down denial.

If the plan misses its own notice or timing rules, the enrollee is deemed to have exhausted the appeal and can ask for a fair hearing directly (438.408(c)(3)). The state then ordinarily decides within 90 days of the plan appeal, or within 3 working days of receiving the case file for an expedited hearing (431.244(f)). The calculator uses 90 days as the safe floor for the hearing request and shows the 120-day outer limit.

What deadlines apply to a Medicare Advantage denial?

Request a reconsideration within 65 days of the date on the notice: the rule says 60 days from receipt and presumes receipt five days after the notice date. The plan decides in 30 days for a service, 60 days for payment, or 72 hours if expedited. An upheld denial goes to independent review automatically.

The filing rule is 42 CFR 422.582 and the decision clocks are in 422.590. A physician's request for an expedited reconsideration must be granted when the physician says the standard time could seriously jeopardize the enrollee; payment appeals can't be expedited. If the plan upholds its denial in whole or in part, or misses its deadline, it must send the case file to the independent review entity (IRE) itself.

After the IRE, an enrollee can ask for a hearing before an administrative law judge within 60 days of receiving the IRE's decision if the amount in dispute meets the threshold, which is $200 in 2026.

Two provider-side details change the route. A contracted provider's payment dispute follows its contract with the plan, not the enrollee appeal process. A non-contracted provider who signs a waiver of liability can request reconsideration within 65 days of the remittance date. For an inpatient psychiatric discharge, the enrollee can ask the Quality Improvement Organization for immediate review no later than the day of discharge.

What are the CMS-0057-F prior-authorization clocks?

Since January 1, 2026, Medicare Advantage plans, Medicaid and CHIP fee-for-service programs and Medicaid managed care plans must decide standard prior-authorization requests within 7 calendar days and expedited requests within 72 hours. Every impacted payer, including marketplace plans on the federal exchange, must give a specific reason for a denial.

Impacted payers also had to post prior-authorization metrics publicly by March 31, 2026, and must offer prior-authorization and data-exchange APIs from 2027. For an appeal, the practical use is simple: if the original request was decided late, or the denial gives only a generic reason, put that in the first paragraph.

Why does the calculator flag weekends and holidays?

Most appeal rules count calendar days and say nothing about weekends, so a deadline can land on a Sunday or a federal holiday. Unless the rule itself moves the date, as the federal external review rule does, the calculator does not assume an extension and points you to the business day before.

Holidays follow the federal list in 5 U.S.C. 6103, with Saturday holidays observed on the Friday before and Sunday holidays on the Monday after. Send early enough that you can prove receipt: a fax transmission report, a certified-mail receipt or a portal confirmation.

If you add a date of service, the calculator also shows 90-day, 180-day and 12-month reference dates. Twelve months is the federal outer limit for Medicare and Medicaid fee-for-service claims (42 CFR 424.44 and 447.45); commercial, Medicare Advantage and Medicaid managed care filing limits come from the provider contract or manual.

What if the appeal deadline has already passed?

Read the notice first: a deadline is only as good as the notice that started it. Medicare Advantage accepts late reconsiderations for good cause stated in writing. Plans that broke the notice or timing rules can lose the right to insist on exhaustion. Otherwise, ask the plan in writing whether it will accept a late appeal.

• Check the notice for missing pieces: the specific reason, the rule or criteria relied on, and a description of the appeal and external review process.
• Check whether the plan decided the original request on time. A late or defective decision can open external review or a fair hearing directly.
• For Medicare Advantage, file the reconsideration with a written good-cause explanation (42 CFR 422.582(c)).
• For a provider claim, check whether a corrected claim or a contract-level dispute is still open even if the member appeal window closed.