Internal Appeal

A formal appeal filed directly with the insurance company (or its behavioral health subcontractor) asking it to reconsider its own denial. ERISA requires plans to provide at least one level of internal appeal. Under 29 CFR 2560.503-1, a group health plan must decide an appeal of an adverse determination within 72 hours for urgent-care claims, 30 days for pre-service claims, and 60 days for post-service claims. (Initial claim decisions are faster: 72 hours urgent, 15 days pre-service, 30 days post-service, each with a limited extension.) Internal-appeal exhaustion is generally required before external-review rights attach.