How long until the insurer responds

The plan's clock starts the day USPS marks your letter delivered, not the day you dropped it in the mail. Here are the regulatory deadlines by plan type, followed by what usually happens in practice.

By the regulation

ERISA group health plans (29 CFR 2560.503-1(i))

• Urgent-care claim: 72 hours
• Pre-service claim: 30 days
• Post-service claim: 60 days
• Concurrent care (ongoing treatment): before care ends
• Plan may take one 60-day extension only for reasons beyond its control

Individual and family plans on the marketplace (45 CFR 147.136(b))

• Urgent: 72 hours
• Pre-service: 30 days
• Post-service: 60 days
• No extension is available for these plans

Medicare Advantage (42 CFR 422.590)

• Standard pre-service reconsideration: 30 days
• Standard payment reconsideration: 60 days
• Expedited reconsideration: 72 hours
• If the plan misses the deadline, the case is auto-forwarded to the IRE

Medicaid managed care (42 CFR 438.408)

• Standard resolution: 30 calendar days
• Expedited resolution: 72 hours
• May be extended up to 14 calendar days at your request or if the plan justifies

In practice

Most first-level decisions land between day 25 and day 55 after delivery. Post-service group health denials pull toward the far end of that range. Pre-service and Medicare Advantage cluster closer to day 30.

Plan for the outer edge. If you have not heard by day 60 (group health) or day 30 (Medicare Advantage standard), start the escalation checklist in What if you don't hear back in 30 days.

What the plan owes you in writing

Under all four regimes, the decision letter must include:

• The specific reason(s) for the decision
• Reference to the specific plan provision on which the decision is based
• A description of any additional information needed to reconsider
• A description of the plan's review procedures and time limits for any further appeal
• A description of your right to bring civil action under ERISA if applicable

Save the letter. Read it in full. If any of those elements is missing, the decision is likely defective and your next step can note that.

What if you do not want to wait

Some situations qualify for expedited review even if you did not check that box originally:

• New clinical development that makes the delay unsafe
• The plan already denied a related claim for the same episode of care

If any of those apply, call the plan's appeals line and request expedited review. Follow up in writing (fax, portal, or email if they provide one) so the request is documented.

The clock does not stop for weekends

Unless the regulation explicitly says "business days," the clock runs on calendar days. Both ERISA and CMS timelines are calendar days.

While you wait

• Do not call to "check on it" more than once. Repeated calls do nothing to speed the review and each call can be misrecorded as a duplicate request
• If the plan requests more information, respond fast, in writing, and keep a copy. See What if my insurer requests more information
• Save every artifact for your paper trail