CMS data from the federal marketplace shows that tens of thousands of eligibility appeals are filed each plan year, and a significant share are resolved in the consumer's favor. The brokers whose clients win those appeals are not the ones who know the most about health insurance. They are the ones who filed in the right process, on the right timeline, with the right documentation.
Key Takeaways
- Grievances (service complaints) and appeals (claim denials) are separate processes with different timelines and different recipients
- The ACA requires plans to resolve urgent care appeals within 72 hours and standard internal appeals within 30 days
- External review by an IRO is available within 4 months of the internal appeal denial for medical necessity and coverage disputes
- Marketplace eligibility appeals go to CMS or the state exchange, not to the health plan; mixing these up wastes weeks
- Brokers need a signed consumer authorization before representing a client in any formal appeal or marketplace dispute process
Three Tracks, Three Sets of Rules
Most client complaints after enrollment fall into one of three categories. Getting the track wrong does not just slow things down; it can permanently waive the client's rights if a filing deadline passes while they are working the wrong channel.
| Track | What it covers | Filed with | Key timeline |
|---|---|---|---|
| Grievance | Service quality, non-claims complaints | Health plan | Plan's own grievance policy (typically 30-60 days to respond) |
| Internal appeal | Claim denials, coverage decisions | Health plan | 180 days to file; plan resolves in 30-60 days |
| External review (IRO) | Medical necessity, rescission, coverage disputes | State or federal external review program | 4 months from internal denial to request |
| Marketplace eligibility appeal | APTC amount, SEP denial, plan placement | CMS or state exchange | 90 days from eligibility notice to request |
Illustrative timelines based on federal ACA requirements. State-based exchanges and individual plan contracts may differ. Verify deadlines from the specific plan or marketplace denial notice before filing.
Grievances: The Service Complaint Track
A grievance is the right tool when the client's complaint is about how the plan treated them, not about a coverage decision. Unreasonable referral delays, provider directory errors, billing disputes that do not involve a formal denial, or customer service failures all go through the grievance process.
The ACA requires plans to have a grievance procedure, but it does not impose the same strict timelines on grievances that it imposes on appeals. Plans typically have 30 to 60 days to respond to a grievance under their own policies. A grievance that is not resolved satisfactorily does not automatically escalate to an appeal; if the underlying issue eventually produces a formal denial, a separate appeal must be filed from that point.
Internal Appeals: The Denial Challenge
When a plan denies a claim, reduces a benefit, or terminates coverage mid-year, the consumer has the right to a formal internal appeal. The ACA sets minimum federal standards for this process that every plan must meet:
- 180 days from the denial notice to file the internal appeal
- Standard appeals resolved within 30 days (pre-service) or 60 days (post-service)
- Urgent care appeals resolved within 72 hours
- Full and fair review by someone not involved in the original decision
- Written explanation of the denial basis and the evidence the plan relied on
During the appeal, the plan must give the consumer access to any new evidence or rationale it relies on and allow the consumer to respond before the decision is final. Brokers helping a client through this process should request a copy of the plan's claim file and the denial rationale in writing before preparing the appeal response.
External Review: When the Internal Process Fails
If the internal appeal is upheld, the consumer typically has 4 months from the internal denial to request external review by an Independent Review Organization. External review applies specifically to:
- Medical necessity determinations
- Experimental or investigational treatment denials
- Rescissions of coverage
External review is not available for marketplace eligibility disputes or disputes about whether the plan or the consumer properly enrolled. The IRO's decision is binding on the health plan. In practice, external review reversal rates for medical necessity denials are meaningful enough that it is worth pursuing when the clinical basis for coverage is sound.
Marketplace Eligibility Appeals: A Separate System
The most commonly misrouted complaints are those involving marketplace eligibility decisions. If a client's APTC was calculated incorrectly, an SEP request was denied, or the marketplace placed them in the wrong plan or coverage tier, those issues are CMS decisions, not health plan decisions.
Filing a claim appeal with the health plan for a marketplace eligibility problem accomplishes nothing. The plan does not control APTC amounts or SEP eligibility; it cannot resolve those disputes. The correct path is the marketplace appeal, which goes to CMS (for FFM states) or to the state exchange (for SBE states). Consumers generally have 90 days from the eligibility determination notice to request a marketplace appeal.
What Brokers Can and Cannot Do
Brokers can assist clients through every step of these processes, but they cannot act as a client's authorized representative without a signed written authorization on file. Some health plans and the marketplace itself have their own authorization forms; others accept a general written authorization signed and dated by the consumer.
Without proper authorization, a broker who submits an appeal or contacts the marketplace on a client's behalf may find the submission rejected, or may inadvertently create a privacy issue. The authorization should be obtained at onboarding and renewed annually, not after a problem arises and the clock is already running on a deadline.
Tracking open client disputes alongside enrollment records is a workflow that pays off during AEP renewals. A client who had a claim denied and never resolved it in the prior year needs to know whether that issue affects their plan selection for the new year before they sign the renewal paperwork.
ACA Grievances and Appeals FAQ
Common questions from brokers and consumers about navigating the ACA's three-track dispute process.
What is the difference between a grievance and an appeal under ACA plans?
A grievance is a complaint about a health plan's service, behavior, or non-claims issue. Common examples include long wait times for referrals, difficulty reaching customer service, or a plan representative's conduct. Grievances do not involve a coverage denial. An appeal is a formal challenge to a plan's decision to deny, reduce, or terminate a covered benefit or payment. The ACA sets specific federal timelines for appeals that do not apply to grievances. If a client's complaint involves a denied claim or a coverage decision, that is an appeal, not a grievance.
How long does a client have to file an internal appeal after a claim denial?
Under ACA rules, consumers have at least 180 days from the date of the denial notice to file an internal appeal with the health plan. Plans must resolve standard internal appeals within 30 calendar days for pre-service claims (before the service) and 60 days for post-service claims (after the service). Urgent care appeals must be resolved within 72 hours. Missing the 180-day filing window typically waives the internal appeal right and may affect access to external review.
What is external review and when is it available?
External review is the process of having an Independent Review Organization, rather than the health plan, evaluate a denied claim or coverage decision. It is available after the internal appeal process is exhausted or, in some urgent situations, can be requested while internal review is pending. Consumers generally have 4 months from the date of the internal appeal denial to request external review. The IRO's decision is binding on the health plan. External review applies to medical necessity denials and rescissions; it does not apply to eligibility disputes with the marketplace.
How is a marketplace eligibility appeal different from a plan appeal?
A marketplace eligibility appeal challenges a decision made by CMS or the state exchange, not by the health plan. Common eligibility appeal triggers include denial or reduction of APTC, denial of a Special Enrollment Period, or placement in an incorrect plan. The appeal goes to the marketplace, not to the insurer. Resolution timelines and processes are different from plan-level appeals. If a client received a lower APTC than expected or was denied an SEP, the correct path is the marketplace appeal, not a claim appeal with the health plan.
Can a broker file an appeal for a client?
A broker can assist a client with an appeal but cannot file or represent the client without a signed written authorization. The appeal is the consumer's right, and CMS and health plans both require written authorization before an agent can act on a consumer's behalf in a dispute. Some plans have a specific authorized representative form; others accept a general written authorization. Brokers who submit an appeal without proper authorization may have the submission rejected, wasting the client's time in a timeline-sensitive process.
