Appeals · 2026
Appeal rights by state.
Which process governs your appeal depends on two things: your state, and whether your employer buys insurance or pays claims itself. The second one surprises almost everybody.
If your employer pays claims from its own money, it is self-funded. Most large employers are.
The three tracks
Under federal rules, external review runs one of three ways. Your state may operate its own process if it meets or exceeds the national model standards. If it does not, the federal Department of Health and Human Services oversees a process instead. And where a plan participates in neither, it must contract with accredited independent review organizations.
Self-funded employer plans always follow the federal track, because federal law preempts state insurance regulation for them.
How to tell which kind of plan you have
- Read your Summary Plan Description. Self-funded plans typically say so directly.
- Ask HR a single question: does the insurer pay claims, or does the company?
- The insurer name on your card tells you nothing — a carrier often just administers a self-funded plan.
Sending an external review request down the wrong track adds weeks, and can push you past a deadline.