What to do when insurance denies therapy

This guide is for parents and adults whose occupational, physical or speech therapy was denied. Find the reason and deadline on the notice, ask the plan for the criteria it used, have the therapist and doctor answer that reason in writing, and appeal by your plan’s route: job-based or Marketplace, Medicare, or Medicaid.

What does it mean when insurance denies therapy?

A denial means the plan has refused to approve or pay for some or all of a therapy service, and its notice must give the reason and explain how to appeal.⁠^9,12,13 Work out which kind you have, because each runs on its own clock:

• A prior authorization denial answers a request made before therapy starts; job-based plans call it a pre-service claim, and HealthCare.gov notes that an approval is not a promise to pay.⁠^1,14
• A claim denial comes after visits, on an explanation of benefits or a letter showing what was not paid; keep those papers for the appeal.⁠²
• A cut to approved therapy reduces or ends a course already approved, which job-based, Medicare Advantage and Medicaid managed care plans each treat as appealable.⁠^1,15,16

The Labor Department counts paying anything less than 100 percent of a claim as a partial denial, but if the plan simply applied your deductible correctly, an appeal has nothing to fix.⁠¹²

What must a therapy denial notice tell you?

A job-based or Marketplace plan’s notice must include these; ask for any that is missing:

• The specific reason, such as not medically necessary, not covered or a treatment maximum reached, and the plan provision relied on.⁠¹²
• Any guideline or criterion used, and for a medical necessity denial the clinical reasoning applied to you, or a statement that you can have either free.⁠¹
• In plans that are not grandfathered, the denial code, the standard used, the diagnosis and treatment codes on request, and your state’s consumer assistance office.⁠³ A job-based plan stays grandfathered only if it has covered someone since March 23, 2010, has not substantially cut benefits or raised costs, and tells members its status.⁠¹⁷

Medicare Advantage and Medicaid managed care notices must also state the reasons and your appeal rights, and a Medicaid notice must offer free copies of the records behind the decision, including its medical necessity criteria.⁠^9,13

Which denial reasons can an appeal answer?

Most of them, though the route depends on the reason.

Should you appeal or ask the clinic to resubmit the claim?

For a possible paperwork error, do both: ask the clinic to correct and resubmit, and keep the appeal deadline in view in case that fails. A job-based plan that receives a pre-service request filed the wrong way must tell you the right procedure within 5 days, or 24 hours when the care is urgent.⁠¹ In Medicaid managed care, a payment denial issued solely because a claim was not a "clean claim" cannot be appealed, so the corrected claim is the fix.⁠¹⁶

A missing or lapsed authorization is often a timing problem: ask whether the plan reviews a request after visits began, and appeal meanwhile. In Medicare Advantage, approval for an active course of treatment must stay valid as long as medically necessary, and a new member mid-treatment gets at least a 90-day transition.⁠²²

Which appeal rules apply to your health plan?

The rules follow who provides the coverage, so identify the plan type from the card or the notice.

For a commercial plan, answer three questions:

• Is it job-based? The Labor Department’s claims rules generally cover private-sector employer plans, not government or most religious ones; the administrator must give you the Summary Plan Description.⁠¹²
• Is it grandfathered? Such a plan need not offer some Affordable Care Act protections, including the assured right to appeal, and your insurer must tell you if it is one; a job-based one still follows the Labor Department’s claims rule.⁠^1,3,17
• Is it insured or self-funded? Self-funded means the employer pays claims from its own money and the insurer only administers them. That sets which external review process applies; the final denial names it.⁠^4,12

A child in a separate Children’s Health Insurance Program still gets an external review of a delay, denial, reduction or end of services.⁠²⁸

How do you appeal a job-based or Marketplace plan’s denial?

File an internal appeal within 180 days of receiving the denial, on the plan’s form or in a letter with your name, claim number and member ID, with anything you want weighed, such as a letter from your therapist or doctor.⁠^1,2

The appeal must be a fresh look: a new decision-maker, not the first one’s subordinate, who gives the first decision no deference, consults a qualified health care professional on medical judgment, and weighs everything you send.⁠¹ You can have free copies of the records relevant to the claim and ask who the plan’s medical experts were.⁠^1,12 Plans that are not grandfathered must show you any new evidence or rationale before deciding, and if one breaks the rules in more than a harmless way, you can go straight to external review.⁠³

When can a therapy appeal be decided as urgent?

When the standard timeline could seriously jeopardize your life or health or your ability to regain maximum function; the plan must then decide within 72 hours.⁠¹ A physician who knows your condition can declare it urgent, and a health care professional who knows your condition can act for you on it without a form.⁠^1,12 You can ask for external review at the same time.⁠²

What happens if the plan cuts therapy it already approved?

Cutting an approved course of treatment before its period or number of visits runs out is an adverse decision, and the plan must tell you early enough to appeal and get a decision before the cut takes effect.⁠¹ A plan that is not grandfathered must keep covering that course while the appeal is pending.⁠³ An urgent request to extend a course, made at least 24 hours before it ends, must be decided within 24 hours.⁠¹ These rules protect a course already approved; they do not approve a new request while you appeal.

How does external review of a therapy denial work?

After a final internal denial, an independent review organization decides if you file within four months of receiving the notice.⁠^3,4 The federal process takes denials involving medical judgment, such as medical necessity, setting or level of care, but not a finding that you were ineligible under the plan.⁠³ Its own first example is a plan covering 30 physical therapy visits, and more only with an approved treatment plan; denying visit 31 is a medical necessity decision eligible for review.⁠³

The reviewer decides within 45 days, or 72 hours when expedited, and if it reverses the denial the plan must immediately cover or pay.⁠^3,4 Your doctor or another medical professional can file it for you.⁠⁴

How do Medicare and Medicare Advantage therapy appeals differ?

They start differently, so follow your notice; the Medicare therapy coverage guide covers what Medicare pays and all 5 levels of appeal.⁠²³

Original Medicare starts with a redetermination, a second look by Medicare’s contractor: file by the date on your Medicare Summary Notice, which the regulation sets at 120 days from receiving it, with receipt presumed 5 days after its date.⁠^6,23

Medicare Advantage starts with the plan’s coverage decision, its organization determination, including a refusal of the type or level of therapy or an early end to an approved course; a medical necessity denial must first be reviewed by a physician or other professional who knows Medicare’s coverage criteria.⁠¹⁵ Ask for a reconsideration within 60 days of receiving the notice, which Medicare.gov states as 65 days from its date; for therapy not yet given, your treating physician can file it after telling you.⁠^5,24 A denial the plan keeps goes to an Independent Review Entity on its own.⁠²⁵

What if Medicare says you stopped improving in therapy?

Point to the standard CMS restated after the Jimmo settlement: Medicare covers skilled therapy in outpatient, home health and skilled nursing settings when you need skilled care to maintain function or slow decline, and coverage does not turn on your potential for improvement.⁠¹⁰ The test is whether a qualified therapist’s judgment and skills are needed for a safe and effective maintenance program, so ask the therapist to explain that in writing.⁠¹⁰

Check the paperwork too: Part B pays for outpatient therapy only with a certified plan of care, the written treatment plan your therapist and doctor sign, recertified at least every 90 days, so ask the clinic whether the doctor’s or practitioner’s certification was complete.⁠²⁹

How do Medicaid therapy appeals work for children and adults?

Appeal to the Medicaid managed care plan within 60 days of the date on the notice, by phone or in writing; a call asking to appeal counts as an appeal.⁠^7,30 The plan has one level of appeal and must resolve it within 30 calendar days, or 72 hours when waiting could seriously jeopardize life, health or the ability to attain, maintain or regain maximum function, with extensions of up to 14 days.⁠^7,26,31

During the appeal, the plan owes you:

• your case file, including medical records, free and in time to use it;⁠³⁰
• decision-makers not involved before, with clinical expertise in your condition for a medical necessity denial;⁠³⁰
• help with forms, interpreters and a toll-free number with TTY;⁠³⁰
• no punishment of a provider who supports your appeal.⁠³¹

Once the plan upholds the denial or misses its deadlines, you can ask for a state fair hearing within the 90 to 120 days the state allows.⁠²⁶ If the plan or hearing reverses a denial, the plan must authorize the therapy within 72 hours of receiving that notice, and the plan or state must pay, under state policy, for disputed visits you had during the appeal.⁠³² Without a managed care plan, you ask the state for a fair hearing directly, within a time it sets of no more than 90 days from the notice’s mailing.⁠²⁷

Can Medicaid keep paying for therapy while you appeal?

Yes, for authorized therapy the plan is cutting, if you act fast. The plan must continue it when you appeal on time about previously authorized services an authorized provider ordered, the authorization has not expired, and you ask for continuation within 10 calendar days of the notice or by the change’s effective date, whichever is later.⁠⁸ Asking again within 10 days of a denied appeal carries it into the fair hearing.⁠⁸ Your therapy provider cannot request continuation for you.⁠⁷ If you lose in the end, the plan may recover the cost of the continued visits, as state policy allows.⁠⁸

Without a managed care plan, the state must generally give notice at least 10 days before cutting services, and a hearing request made before that date keeps them in place until the decision, apart from narrow exceptions, with the same risk of repayment.⁠^33,34

What does EPSDT mean for a child’s denied therapy?

For a child under 21 in Medicaid, EPSDT (Early and Periodic Screening, Diagnostic and Treatment) requires the state to furnish medically necessary, Medicaid-coverable services needed to correct or ameliorate the child’s conditions, whether or not the state plan lists them, decided case by case.⁠¹¹ Ask whether the plan reviewed the request under that standard, and have the therapist’s letter say how therapy corrects or ameliorates the condition. EPSDT does not reach an adult’s appeal; for school therapy and state mandates, see insurance and therapy for children.⁠¹¹

What should you ask your therapist and doctor for?

Ask the treating therapist for a letter that answers the plan’s stated reason, and the doctor for whatever the payer requires from a physician; Medicare.gov and HealthCare.gov both point you to your providers for this.⁠^2,35 A letter of medical necessity from the occupational therapist, physical therapist or speech-language pathologist about their own therapy covers:

• the diagnosis and what it keeps you or your child from doing at home, school or work;
• evaluation findings, including standardized test results;
• measurable goals, planned frequency and length, and why a therapist’s skills are needed;
• progress so far or, under Medicare, the skilled need to maintain function;⁠¹⁰
• each of the plan’s criteria, answered in the plan’s own wording.

Ask for the plan’s own definition of medically necessary, which is the one it applies; HealthCare.gov’s general one is care needed to diagnose or treat a condition that meets accepted standards of medicine.⁠^3,36

Who does what in an appeal: therapist, doctor or you?

Each role differs by discipline and payer:

• The therapist explains the skilled need for their own discipline; an occupational therapist’s letter does not speak for speech therapy.
• The doctor or nonphysician practitioner certifies the Medicare Part B plan of care, and in Medicaid prescribes physical and occupational therapy or refers for speech services.⁠^29,37
• In Medicare Advantage, a treating provider can request the first decision, a treating physician can request reconsideration of therapy not yet given, and a physician’s statement that waiting is dangerous makes the plan expedite.⁠^15,24,38
• In Medicaid managed care, a provider can appeal for you with your written consent where state law permits.⁠⁷

No therapist can decide coverage or promise approval, and none should alter a diagnosis, a code or a service description to fit the criteria.

How fast must a clinic give you therapy records for an appeal?

Within 30 days of your request, with one extension of up to 30 days, in the format you ask for if readily producible, for no more than a reasonable, cost-based fee, so ask early.⁠³⁹ A parent with authority under state law over a child’s care is generally the child’s personal representative for records, with exceptions such as care a minor may lawfully consent to alone.⁠⁴⁰ An adult can direct the clinic in a signed written request to send copies to a family member.⁠⁴¹

What should a therapy appeal letter say?

It should identify the decision, say what you want, answer the stated reason with evidence, and list what you enclose; for Medicare Advantage, include your address and Medicare Number, the services and dates, and proof of any representative.⁠⁵ A commercial plan’s form, or a letter with your name, claim number and member ID, starts the appeal.⁠²

Keep your originals and send copies by a method that records delivery, such as certified mail with a return receipt.⁠^2,12 Medicare counts an appeal as filed when the plan or contractor receives it, so send it well before the deadline.⁠^6,24

What should you ask the plan when you call about a denial?

Ask for the reason, the criteria and both deadlines, and note the day, time, name and title of each person you speak with.⁠² Ask for language help if you need it: plans that are not grandfathered must offer it where 10 percent or more of a county’s residents are literate only in the same non-English language, and Medicaid plans must offer interpreters and TTY.⁠^3,30

Who pays for therapy while a denial is under appeal?

Two rules keep therapy covered during an appeal, each for therapy already approved or under way, and Medicare adds a fast decision:

• Job-based and Marketplace plans that are not grandfathered keep covering an approved course while you appeal its cut.⁠³
• Medicaid continues authorized therapy when you ask in time, with the risk of repaying if you lose.⁠^8,34
• Medicare gives you the right to a fast appeal when covered skilled nursing facility, home health or comprehensive outpatient rehabilitation facility services are ending too soon; the written notice your provider gives you says how to ask, and the fast part is the decision, so ask the moment you get the notice.⁠³⁵

None of these rules puts the clinic’s bill on hold: the appeal is between you and the plan. Ask the clinic in writing whether it can hold the account, whether its contract with your plan lets it bill you for denied visits, and what each visit costs if you continue; ask your therapist whether to continue, pause or use a home program.

If you keep going and pay without a claim going to your job-based or individual plan, you count as self-pay, so the clinic must give you a written good faith estimate within 3 business days of asking; any question about cost counts as a request.⁠⁴² The rule also treats someone whose plan has no benefits for the service as uninsured.⁠⁴² Ask the plan whether those visits could still be claimed later. See the guides to adult therapy without insurance, children’s therapy without insurance, physical therapy costs and adult occupational therapy costs.

Who can help with a therapy appeal for free?

Start with the office named on your notice:

• Your state’s Consumer Assistance Program can file an appeal for you; where a state has none, CMS’s map points to the state insurance department and the Department of Labor.⁠^2,43
• Your state insurance department takes complaints about insurers and may be able to help with an appeal.⁠^4,44
• The Employee Benefits Security Administration answers questions about job-based plans at 1-866-444-3272.⁠¹²
• Your State Health Insurance Assistance Program counsels people with Medicare for free.⁠³⁵
• Your Medicaid plan must give reasonable help with forms and procedural steps.⁠³⁰

Filing should cost nothing: plans generally cannot charge for filing claims and appeals.⁠¹²

What does a therapy appeal look like for a child and an adult?

Should you switch clinics after a therapy denial?

Only if the reason is about the clinic, such as being out of network; a new clinic does not change an exclusion, a visit limit or a medical necessity decision. For an out-of-network denial, ask whether the plan makes an exception when the therapy cannot be provided effectively in network, a question of medical judgment open to external review.⁠³ The no in-network therapist guide covers what each kind of plan owes when its network has no opening.

When you need another clinic, DrSensory’s directory is free for families and lists occupational, physical and speech therapy clinics for children and adults, which you can filter by location. It lists clinics, not individual therapists, and does not verify clinical quality, so confirm with your plan, by name and address, that a clinic is in network before you book. A message you send through DrSensory is read by the clinic in its portal, and the clinic replies from its own address.

Sources

1. 29 CFR. §2560.503-1, Claims procedure (the Department of Labor rule for employee benefit plans, which 45 CFR 147.136 also applies to insurers). Checked October 24, 2026.
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   (a): “these requirements apply to every employee benefit plan described in section 4(a) and not exempted under section 4(b) of the Act”; (b)(4): “a health care professional, within the meaning of paragraph (m)(7) of this section, with knowledge of a claimant’s medical condition shall be permitted to act as the authorized representative of the claimant”; (c)(1)(i), a pre-service claim filed the wrong way “shall be notified of the failure and the proper procedures to be followed in filing a claim for benefits” and “not later than 5 days (24 hours in the case of a failure to file a claim involving urgent care) following the failure”; (f)(2)(ii)(A), an approved ongoing course of treatment “at a time sufficiently in advance of the reduction or termination to allow the claimant to appeal and obtain a determination on review of that adverse benefit determination before the benefit is reduced or terminated”; (f)(2)(ii)(B): “within 24 hours after receipt of the claim by the plan, provided that any such claim is made to the plan at least 24 hours prior to the expiration of the prescribed period of time or number of treatments”; (g)(1)(v): “a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request”; “an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant’s medical circumstances”; (h)(2)(iii): “upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits”; (h)(2)(iv): “takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim”; (h)(3)(i): “Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination”; (h)(3)(ii): “neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual”; (h)(3)(iii): “shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment”; (i)(2)(i): “not later than 72 hours after receipt of the claimant’s request for review of an adverse benefit determination by the plan”; (i)(2)(ii): “such notification shall be provided not later than 30 days after receipt by the plan of the claimant’s request for review”; (i)(2)(iii)(A): “such notification shall be provided not later than 60 days after receipt by the plan of the claimant’s request for review”; (m)(1)(i)(A): “Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function”; (m)(2): “on approval of the benefit in advance of obtaining medical care”.
2. Centers for Medicare & Medicaid Services (HealthCare.gov). Internal appeals (how to appeal an insurance company decision). Checked October 24, 2026.
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   “You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.”; “Submit any additional information that you want the insurer to consider, such as a letter from the doctor.”; “Or you can write to your insurer with your name, claim number, and health insurance ID number.”; “The Consumer Assistance Program in your state can file an appeal for you.”; “If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal.”; “Include the day, time, name, and title of the person you talked to and details about the conversation.”; “Keep your original documents and submit copies to your insurance company.”; “The Explanation of Benefits forms or letters showing what payment or services were denied”.
3. 45 CFR. §147.136, Internal claims and appeals and external review processes (the federal appeal rules for non-grandfathered group and individual plans). Checked October 24, 2026.
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   (a)(1)(ii): “The provisions of this section generally do not apply to coverage offered by health insurance issuers and group health plans that are grandfathered health plans”; (b)(2)(ii)(C): “A plan and issuer must allow a claimant to review the claim file and to present evidence and testimony as part of the internal claims and appeals process.”; (b)(2)(ii)(C)(1): “The plan or issuer must provide the claimant, free of charge, with any new or additional evidence considered, relied upon, or generated by the plan or issuer”; (b)(2)(ii)(E)(2): “upon request, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning, associated with any adverse benefit determination or final internal adverse benefit determination”; (b)(2)(ii)(E)(3): “includes the denial code and its corresponding meaning, as well as a description of the plan’s or issuer’s standard, if any, that was used in denying the claim”; (b)(2)(ii)(E)(5): “contact information for, any applicable office of health insurance consumer assistance or ombudsman”; (b)(2)(ii)(F)(1): “the claimant is deemed to have exhausted the internal claims and appeals process”; “Accordingly the claimant may initiate an external review”; (b)(2)(ii)(F)(2), except for “de minimis violations that do not cause, and are not likely to cause, prejudice or harm to the claimant”; (b)(2)(iii): “are required to provide continued coverage pending the outcome of an appeal”; “benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice and an opportunity for advance review”; (d)(1)(i)(A), the federal external review covers a denial that “involves medical judgment (including, but not limited to, those based on the plan’s or issuer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit” but “A denial, reduction, termination, or a failure to provide payment for a benefit based on a determination that a participant, beneficiary, or enrollee fails to meet the requirements for eligibility” is not eligible for it. Example 1: “A group health plan provides coverage for 30 physical therapy visits generally.”; “coverage is provided only if the service is preauthorized pursuant to an approved treatment plan that takes into account medical necessity using the plan’s definition of the term”; “the plan’s denial of benefits is based on medical necessity and involves medical judgment. Accordingly, the claim is eligible for external review”; Example 2 “the plan’s denial of benefits is based on whether a service can effectively be provided in network and, therefore, involves medical judgment”; (d)(2)(i): “within four months after the date of receipt of a notice of an adverse benefit determination or final internal adverse benefit determination”; “must provide written notice of the final external review decision within 45 days after the IRO receives the request for the external review”; “the plan or issuer immediately must provide coverage or payment (including immediately authorizing care or immediately paying benefits) for the claim”; (d)(3)(iv): “but in no event more than 72 hours after the IRO receives the request for an expedited external review”; (e)(2)(i): “must provide oral language services (such as a telephone customer assistance hotline)”; (e)(3): “ten percent or more of the population residing in the county is literate only in the same non-English language”.
4. Centers for Medicare & Medicaid Services (HealthCare.gov). External review (how to appeal an insurance company decision). Checked October 24, 2026.
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   “You must file a written request for an external review within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied.”; “Your insurer is required by law to accept the external reviewer’s decision.”; “You may appoint a representative (like your doctor or another medical professional) who knows about your medical condition to file an external review on your behalf.”; “If your health insurance company is using the HHS-Administered Federal External Review Process, there’s no charge.”; “the charge can’t be more than $25 per external review”; “Check the information on your Explanation of Benefits (EOB) or on the final denial of the internal appeal by your health plan. It’ll give you the contact information for the organization that will handle your external review.”; “If you need help filing an internal appeal or external review, your state’s Consumer Assistance Program (CAP) or Department of Insurance”.
5. Centers for Medicare & Medicaid Services (Medicare.gov). Appeals in Medicare health plans (Medicare Advantage appeals). Checked October 24, 2026.
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   “must file an appeal within 65 days from the date on the initial denial notice sent by your plan”; “If you miss the deadline, you must give a reason for filing late.”; “Your name, address, and the Medicare Number on your”; “The items or services you’re appealing, the dates of service, and the reason(s) why you’re appealing.”; “The name of your representative and proof of representation, if you’ve appointed a representative.”; “If your appeal is for a service you haven’t gotten yet, your doctor can ask for a reconsideration on your behalf (and must notify you about it).”; “Pre-service appeal: 30 days”; “Payment appeal: 60 days”; “If the plan decides against you (fully or partially), your appeal is automatically sent to level 2.”
6. 42 CFR. §405.942, Time frame for filing a request for a redetermination (Original Medicare). Checked October 24, 2026.
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   (a): “any request for redetermination must be filed within 120 calendar days from the date a party receives the notice of the initial determination”; (a)(1): “presumed to be 5 calendar days after the date of the notice of initial determination, unless there is evidence to the contrary”; (a)(2): “The request is considered as filed on the date it is received by the contractor.”; (b)(3)(iv), good cause includes “The contractor gave the party incorrect or incomplete information about when and how to request a redetermination”.
7. 42 CFR. §438.402, General requirements (Medicaid managed care). Checked October 24, 2026.
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   (b): “Each MCO, PIHP, and PAHP may have only one level of appeal for enrollees.”; (c)(1)(i)(B): “The State may offer and arrange for an external medical review”; it “must be at the enrollee’s option and must not be required before or used as a deterrent to proceeding to the State fair hearing” and “The review must be offered without any cost to the enrollee.”; (c)(1)(ii): “If State law permits and with the written consent of the enrollee, a provider or an authorized representative may request an appeal or file a grievance, or request a State fair hearing, on behalf of an enrollee.”; “providers cannot request continuation of benefits”; (c)(2)(ii): “an enrollee has 60 calendar days from the date on the adverse benefit determination notice in which to file a request for an appeal to the managed care plan”; (c)(3)(ii): “The enrollee may request an appeal either orally or in writing.”
8. 42 CFR. §438.420, Continuation of benefits while the MCO, PIHP, or PAHP appeal and the State fair hearing are pending (Medicaid managed care). Checked October 24, 2026.
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   (a): “Within 10 calendar days of the MCO, PIHP, or PAHP sending the notice of adverse benefit determination.”; “The intended effective date of the MCO’s, PIHP’s, or PAHP’s proposed adverse benefit determination.”; (b)(2): “The appeal involves the termination, suspension, or reduction of previously authorized services;”; (b)(3): “The services were ordered by an authorized provider;”; (b)(4): “The period covered by the original authorization has not expired; and”; (d): “recover the cost of services furnished to the enrollee while the appeal and state fair hearing was pending”; (c)(2), continued benefits end if “The enrollee fails to request a state fair hearing and continuation of benefits within 10 calendar days after the MCO, PIHP, or PAHP sends the notice of an adverse resolution to the enrollee’s appeal”.
9. 42 CFR. §438.404, Timely and adequate notice of adverse benefit determination (Medicaid managed care). Checked October 24, 2026.
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   (b)(2): “The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee’s adverse benefit determination.”; “Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits.”
10. Centers for Medicare & Medicaid Services. Jimmo Settlement (Important Message About the Jimmo Settlement). Checked October 24, 2026.
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    “clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met)”; “does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care”; “Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program.”
11. Centers for Medicare & Medicaid Services (Medicaid.gov). Early and Periodic Screening, Diagnostic, and Treatment. Checked October 24, 2026.
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    “provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid”; “States are required to furnish all 1905(a) Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines.”; “regardless of whether the service is covered in a state’s Medicaid plan. It is the responsibility of states to determine medical necessity on a case-by-case basis.”
12. U.S. Department of Labor, Employee Benefits Security Administration. Filing a Claim for Your Health Benefits (consumer booklet). Checked October 24, 2026.
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    “generally apply to people who receive health benefits from a private-sector employment plan. However, there are exceptions for plans sponsored by government or most religious bodies.”; “If you do not have a copy of your plan’s Summary Plan Description or claims procedures, contact your plan’s administrator, who is required to provide you with a copy.”; “In the case of a claim involving urgent care, the treating physician can automatically act as your authorized representative without you having to complete a form.”; “plans generally cannot charge any money for filing claims and appeals”; “If an authorized representative is filing the claim on your behalf, your plan may require you to complete a form to name the representative.”; “You may also want to send the letter by certified mail, return receipt requested, so you will have a record that the letter was received and by whom.”; “If a physician with knowledge of your medical condition tells the plan that a pre-service claim is urgent, the plan must treat it as an urgent care claim.”; “paying anything less than 100 percent of a claim is a denial in part”; “A reference to any specific plan provision relied upon for the denial”; “A description of the plan’s review procedures (for example, how appeals work and/or how to initiate an appeal)”; “check your Summary Plan Description or claims procedure to see if your plan provides a longer period”; “Specific reasons for denial (for example, not medically necessary, not covered by the plan, or reached maximum amount of treatment permitted under the plan)”; “You can also request the identity of any medical or vocational expert whose advice was obtained by the plan.”; “The external review process used by the plan depends on whether the plan is self-funded or provides benefits through an insurance company.”; “call toll free 1-866-444-3272”.
13. 42 CFR. §422.568, Standard timeframes and notice requirements for organization determinations (Medicare Advantage). (e)(2): “State the specific reasons for the denial”; (e)(3): “Inform the enrollee of his or her right to a reconsideration”. Checked October 24, 2026.
14. Centers for Medicare & Medicaid Services (HealthCare.gov). Preauthorization (glossary). “Preauthorization isn’t a promise your health insurance or plan will cover the cost.” Checked October 24, 2026.
15. 42 CFR. §422.566, Organization determinations (Medicare Advantage). Checked October 24, 2026.
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    (b)(3): “to provide or pay for services, in whole or in part, including the type or level of services”; (b)(4): “Reduction, or premature discontinuation, of a previously authorized ongoing course of treatment.”; (c)(1)(ii): “Any provider that furnishes, or intends to furnish, services to the enrollee”; (d): “must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the services at issue, including knowledge of Medicare coverage criteria”.
16. 42 CFR. §438.400, Statutory basis, definitions, and applicability (Medicaid managed care grievances and appeals). an adverse benefit determination includes “The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.”; “The reduction, suspension, or termination of a previously authorized service.”; “A denial, in whole or in part, of a payment for a service solely because the claim does not meet the definition of a “clean claim” at § 447.45(b) of this chapter is not an adverse benefit determination.”; “Appeal means a review by an MCO, PIHP, or PAHP of an adverse benefit determination.”; “Grievance means an expression of dissatisfaction about any matter other than an adverse benefit determination.”; “Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee”; “Grievance includes an enrollee’s right to dispute an extension of time proposed by the MCO, PIHP or PAHP to make an authorization decision.” Checked October 24, 2026.
17. Centers for Medicare & Medicaid Services (HealthCare.gov). Grandfathered health insurance plans (rights and protections). Checked October 24, 2026.
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    “Your insurer must notify you if you have a grandfathered plan.”; job-based grandfathered plans keep the status if they “Haven’t been changed to substantially cut benefits or increase costs for plan holders”, “Notify plan holders they have a grandfathered plan” and “Have continuously covered at least one person since March 23, 2010”; “Grandfathered plans don’t have to offer some rights and protections Marketplace plans do.”; its comparison table lists “Guarantee your right to appeal a coverage decision” with “No” for grandfathered plans and “Yes” for Marketplace plans.
18. 45 CFR. §156.115, Provision of EHB (essential health benefits). Checked October 24, 2026.
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    (a)(6)(i): “Cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services). Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology”; (a)(6)(ii): “Do not impose limits on coverage of habilitative services and devices that are less favorable than any such limits imposed on coverage of rehabilitative services and devices”; (a)(6)(iii): “For plan years beginning on or after January 1, 2017, do not impose combined limits on habilitative and rehabilitative services and devices.”
19. Centers for Medicare & Medicaid Services. Information on Essential Health Benefits (EHB) Benchmark Plans. The Affordable Care Act requires non-grandfathered coverage “in the individual and small group markets to cover essential health benefits (EHB)”; including “(7) rehabilitative and habilitative services and devices”. Checked October 24, 2026.
20. 34 CFR. §300.34, Related services (IDEA). (a): “such developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education, and includes speech-language pathology and audiology services”; “physical and occupational therapy”. Checked October 24, 2026.
21. 34 CFR. §300.17, Free appropriate public education (IDEA). (a): “Are provided at public expense, under public supervision and direction, and without charge”. Checked October 24, 2026.
22. 42 CFR. §422.112, Access to services (Medicare Advantage). Checked October 24, 2026.
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    (b)(8)(i)(A): “Approval of a prior authorization request for a course of treatment must be valid for as long as medically necessary to avoid disruptions in care”; (b)(8)(i)(B): “A minimum 90-day transition period for any active course(s) of treatment when an enrollee has enrolled in an MA plan after starting a course of treatment, even if the service is furnished by an out-of-network provider.”
23. Centers for Medicare & Medicaid Services (Medicare.gov). Appeals in Original Medicare. Checked October 24, 2026.
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    “There are 5 levels of appeal.”; “You must file your appeal by the date in the MSN.”; “You’ll generally get a decision from the Medicare Administrative Contractor (MAC) within 60 days after they get your appeal.”; “You have 180 days after you get the MAC’s decision letter or an MSN to ask for a level 2 appeal”.
24. 42 CFR. §422.582, Request for a standard reconsideration (Medicare Advantage). Checked October 24, 2026.
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    (a): “a physician who is treating an enrollee and acting on the enrollee’s behalf”; (b): “a request for reconsideration must be filed within 60 calendar days after receipt of the written organization determination notice”; (b)(1): “presumed to be 5 calendar days after the date of the written organization determination, unless there is evidence to the contrary”; (b)(2): “the request is considered as filed on the date it is received by the plan or delegated entity specified in the MA organization’s written organization determination”; (c)(1): “If a party or physician acting on behalf of an enrollee shows good cause, the MA organization may extend the timeframe for filing a request for reconsideration.”
25. 42 CFR. §422.590, Timeframes and responsibility for reconsiderations (Medicare Advantage). Checked October 24, 2026.
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    (a)(1): “no later than 30 calendar days from the date it receives the request for a standard reconsideration”; (a)(2): “send the case file to the independent entity contracted by CMS”; (b)(1): “no later than 60 calendar days from the date it receives the request for a standard reconsideration”; (e)(1): “no later than 72 hours after receiving the request”.
26. 42 CFR. §438.408, Resolution and notification: Grievances and appeals (Medicaid managed care). Checked October 24, 2026.
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    (b)(2): “no longer than 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal”; (b)(3): “no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal”; (c)(1): “may extend the timeframes from paragraph (b) of this section by up to 14 calendar days”; (c)(3): “the enrollee is deemed to have exhausted the MCO’s, PIHP’s, or PAHP’s appeals process. The enrollee may initiate a State fair hearing.”; (f)(1): “An enrollee may request a State fair hearing only after receiving notice that the MCO, PIHP, or PAHP is upholding the adverse benefit determination.”; (f)(2): “no less than 90 calendar days and no more than 120 calendar days from the date of the MCO’s, PIHP’s, or PAHP’s notice of resolution to request a State fair hearing”.
27. 42 CFR. §431.221, Request for hearing (Medicaid fair hearings). (d): “The agency must allow the applicant or beneficiary a reasonable time, not to exceed 90 days from the date that notice of action is mailed”. Checked October 24, 2026.
28. 42 CFR. §457.1130, Program specific review process: Matters subject to review (the Children’s Health Insurance Program). Checked October 24, 2026.
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    (b): “A State must ensure that an enrollee has an opportunity for external review of a”; (b)(1): “Delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services”.
29. 42 CFR. §424.24, Requirements for medical and other health services furnished by providers under Medicare Part B. Checked October 24, 2026.
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    (b): “Medicare Part B pays for medical and other health services furnished by providers (and not exempted under paragraph (a) of this section) only if a physician certifies the content specified in paragraph (c)(1) or (4)”; (c)(3)(ii): “If the plan of treatment is established by a physical therapist, occupational therapist, or speech-language pathologist, the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case, except as specified in paragraph (c)(5) of this section.”; (c)(4)(i): “Recertification is required at least every 90 days.”
30. 42 CFR. §438.406, Handling of grievances and appeals (Medicaid managed care). Checked October 24, 2026.
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    (a): “must give enrollees any reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal”; including “auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability”; (b)(2)(ii): “are individuals who have the appropriate clinical expertise, as determined by the State, in treating the enrollee’s condition or disease”; (b)(3): “oral inquiries seeking to appeal an adverse benefit determination are treated as appeals”; (b)(5): “the enrollee’s case file, including medical records”; “This information must be provided free of charge”.
31. 42 CFR. §438.410, Expedited resolution of appeals (Medicaid managed care). (a): “could seriously jeopardize the enrollee’s life, physical or mental health, or ability to attain, maintain, or regain maximum function”; (b): “punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee’s appeal”. Checked October 24, 2026.
32. 42 CFR. §438.424, Effectuation of reversed appeal resolutions (Medicaid managed care). Checked October 24, 2026.
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    (a): “must authorize or provide the disputed services promptly and as expeditiously as the enrollee’s health condition requires but no later than 72 hours from the date it receives notice reversing the determination”; (b): “the enrollee received the disputed services while the appeal was pending, the MCO, PIHP, or PAHP, or the State must pay for those services, in accordance with State policy and regulations”.
33. 42 CFR. §431.211, Advance notice (Medicaid fair hearings). “The State or local agency must send a notice at least 10 days before the date of action”. Checked October 24, 2026.
34. 42 CFR. §431.230, Maintaining services (Medicaid fair hearings). Checked October 24, 2026.
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    (a): “the beneficiary requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing”; (b): “the agency may institute recovery procedures against the applicant or beneficiary to recoup the cost of any services furnished the beneficiary”.
35. Centers for Medicare & Medicaid Services (Medicare.gov). Filing an appeal (claims, appeals and complaints). Checked October 24, 2026.
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    “Before you start an appeal, you can ask your provider or supplier for any information to make your appeal stronger.”; “SHIPs are state programs that get money from the federal government to give free local health insurance counseling to people with Medicare.”; “If you have a trusted family member or friend helping you with a complaint, you can appoint them as a representative.”; “fast appeal if you think your Medicare-covered services are ending too soon. This includes services you get from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice.”
36. Centers for Medicare & Medicaid Services (HealthCare.gov). Medically necessary (glossary). “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.” Checked October 24, 2026.
37. 42 CFR. §440.110, Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Medicaid). Checked October 24, 2026.
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    (a)(1) and (b)(1): “services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law”; (c)(1): “for which a patient is referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law”.
38. 42 CFR. §422.570, Expediting certain organization determinations (Medicare Advantage). Checked October 24, 2026.
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    (c)(2)(ii): “For a request made or supported by a physician, the MA organization must provide an expedited determination if the physician indicates that applying the standard timeframe for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.”
39. 45 CFR. §164.524, Access of individuals to protected health information (the HIPAA right of access). Checked October 24, 2026.
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    (a)(1): “an individual has a right of access to inspect and obtain a copy of protected health information about the individual in a designated record set”; (b)(2)(i): “the covered entity must act on a request for access no later than 30 days after receipt of the request”; (b)(2)(ii): “may extend the time for such actions by no more than 30 days”; (c)(2)(i): “in the form and format requested by the individual, if it is readily producible in such form and format”; (c)(4): “may impose a reasonable, cost-based fee”.
40. 45 CFR. §164.502, Uses and disclosures of protected health information: General rules (personal representatives). Checked October 24, 2026.
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    (g)(3)(i): “If under applicable law a parent, guardian, or other person acting in loco parentis has authority to act on behalf of an individual who is an unemancipated minor in making decisions related to health care, a covered entity must treat such person as a personal representative”; with exceptions including when “The minor may lawfully obtain such health care service without the consent of a parent, guardian, or other person acting in loco parentis, and the minor, a court, or another person authorized by law consents to such health care service”.
41. U.S. Department of Health and Human Services, Office for Civil Rights. Under HIPAA, when can a family member of an individual access the individual’s PHI from a health care provider or health plan? (HIPAA FAQ). Checked October 24, 2026.
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    “The individual’s request must be in writing, signed by the individual, and clearly identify the designated person and where to send the PHI.”
42. 45 CFR. §149.610, Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals. Checked October 24, 2026.
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    (a)(2)(xiii)(A), uninsured includes “An individual who does not have benefits for an item or service under a group health plan”; (a)(2)(xiii)(B), self-pay includes someone with a group plan, an insurer’s policy or the federal employees’ plan “but who does not seek to have a claim for such item or service submitted to such plan or coverage”; (b)(1)(iv): “shall consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate”; (b)(1)(vi)(C): “Not later than 3 business days after the date of the request.”
43. Centers for Medicare & Medicaid Services. Consumer Assistance Program (state map). “If your State doesn’t have a CAP, the map will direct you to other possible resources – such as the State Department of Insurance and the US Department of Labor”. Checked October 24, 2026.
44. National Association of Insurance Commissioners. Insurance Departments (directory). “Having a problem with an insurance company or agent? Find your state insurance department and file a complaint.” Checked October 24, 2026.
45. 34 CFR. §104.33, Free appropriate public education (Section 504). (a): “shall provide a free appropriate public education to each qualified handicapped person who is in the recipient’s jurisdiction”; (b)(1): “the provision of regular or special education and related aids and services that (i) are designed to meet individual educational needs”. Checked October 24, 2026.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider about your individual situation.