Commercial Payer Appeal Levels and Timely-Filing Windows

Appealing a Commercial Payer Denial#

When a claim is denied, providers (and patients) have the right to appeal. Commercial / ERISA plans generally follow a tiered process, distinct from Medicare's process.

Level 1 — Internal appeal (reconsideration / redetermination request to the plan). The provider submits a written appeal to the same payer that denied the claim, including a cover letter, the original claim, the remittance advice showing the CARC/RARC, and supporting documentation (clinical notes, proof of authorization, proof of timely filing). The plan re-reviews internally. Deadlines to *file* commonly range from 60 to 180 days from the denial, and the plan typically must *respond* within 30 days (pre-service) or 60 days (post-service) under federal claims-procedure rules for ERISA plans.

Level 2 — Second-level internal appeal. If the first appeal is upheld, many plans offer a second internal review, sometimes by a different reviewer or a medical director for clinical denials (peer-to-peer review).

Level 3 — External review (Independent Review Organization). After internal appeals are exhausted, the Affordable Care Act guarantees a right to an independent external review by an unaffiliated third party for many denials (especially medical-necessity and coverage determinations). The IRO decision is binding on the plan. The standard window to request external review is generally 4 months (120 days) from the final internal denial.

Expedited / urgent appeals. When a delay would seriously jeopardize the patient's health, both internal and external appeals can be expedited, often with decisions within 72 hours.

Practical keys to a successful appeal:

• Appeal the specific reason in the CARC/RARC, not generically.
• Stay inside the timely-filing window — late appeals are routinely dismissed.
• Attach proof: documentation that directly rebuts the stated denial reason.
• Track every appeal's status and deadline; unworked appeals are abandoned revenue.