What if you don't hear back in 30 days

Silence at 30 days is normal for a group health post-service appeal and not normal for a Medicare Advantage standard pre-service reconsideration. Here is the timeline by plan type and what to do at each point.

Not yet a problem

• ERISA group health post-service: 60 days is the deadline (29 CFR 2560.503-1(i)(2)(iii)(A)). 30 days is normal.
• Marketplace individual and family post-service: same 60-day deadline (45 CFR 147.136(b)(2)).
• Medicare Advantage standard payment reconsideration: 60 days.

Getting close

• ERISA group health pre-service: 30-day deadline. At day 25 you are late for a response.
• Marketplace individual and family pre-service: same 30-day deadline.
• Medicare Advantage standard pre-service reconsideration: 30-day deadline.
• Medicaid managed care standard resolution: 30 calendar days.

Immediate problem

• Urgent-care claims across all four regimes: 72 hours.
• Any expedited reconsideration you requested: 72 hours.
• Any deadline that has passed.

What to do at day 30 (or day 60 for post-service)

Step 1. Check tracking. Open the usps.com tracking page. Confirm the letter was delivered. Note the delivery date. The clock starts on the delivery date, not the mailing date.

Step 2. Call the plan. Call the appeals line (not general member services). Ask: "I filed a written appeal received by your office on [date]. What is the status?" Get a reference number, agent first name, and date of the call.

Step 3. Send a follow-up letter. If the call does not produce a written status or a decision date, send a short follow-up letter noting:

• The date the plan received your original appeal (with the tracking number as proof)
• The regulatory deadline (cite the CFR)
• Your request for a written decision within seven days

Step 4. Escalate. If day 60 passes with no decision on a post-service group health appeal, or day 30 for pre-service, you have grounds to escalate:

• Under ERISA, when the plan fails to follow its own procedures, you may deem your administrative remedies exhausted and proceed to external review or civil action (see 29 CFR 2560.503-1(l))
• For Medicare Advantage, missed deadlines auto-forward to the IRE
• File a complaint with your state DOI: How to escalate to your state insurance department
• If ERISA plan, file a complaint with the US Department of Labor Employee Benefits Security Administration (EBSA)

What "deemed exhaustion" means

For ERISA plans, missing the deadline is a big deal. It means the plan has failed to provide a "full and fair review," and you can:

• Request external review immediately without waiting for a first-level decision
• Sue in federal court under ERISA section 502(a)(1)(B)
• Ask for de novo review rather than the deferential standard the plan would normally get

This is a strong tool. Do not use it recklessly. But do not let it lapse either.

When to hire an attorney

If a plan repeatedly ignores you or the missed deadline is on a high-dollar claim, an ERISA attorney can send a demand letter that gets a response. See When to hire an ERISA attorney.