How do I file a health insurance claim through my job's plan, and how long do they have to decide?

Health insuranceHow to fileChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: eCFR · 29 CFR 2560.503-1 · § 2560.503-1(b)(2), (b)(4), (e) View original ↗

In short

Get your plan's booklet, called the SPD. It says where to file.
Keep a copy of every claim and letter you send.
For care you already got, the plan has 30 days to decide, plus 15 more.

What this means

Federal rules say your job-based plan must have a claims process. Your summary plan description (SPD) must describe it, with the time limits [1]. A claim is a request you make under the plan's filing rules [1]. So file the way your SPD says.

Someone else can file or appeal for you. The plan may have its own steps to check that the person can act for you [1].

How long the plan has [2]: • Care you already got: no later than 30 days after the plan gets the claim. The plan may add up to 15 more days one time. • Approval before care: no later than 15 days. • Urgent care: no later than 72 hours.

If the plan says no, it must give you at least 180 days to appeal [2].

Your next step

Get your SPD and file the claim the way it says [1]. For care you already got, expect a decision within 30 days, or 45 if the plan takes the extra time [2]. If it's denied, you have at least 180 days to appeal [2].

Check it yourself

Read the claims part of your SPD. The federal rule is 29 CFR 2560.503-1 on eCFR.gov. The Department of Labor's own guide page could not be opened here — "Don't know yet" what it adds.

Where this comes from (2)

[1] eCFR · 29 CFR 2560.503-1 · § 2560.503-1(b)(2), (b)(4), (e) · checked 2026-11-06
A description of all claims procedures (including, in the case of a group health plan within the meaning of paragraph (m)(6) of this section, any procedures for obtaining prior approval as a prerequisite for obtaining a benefit, such as preauthorization procedures or utilization review procedures) and the applicable time frames is included as part of a summary plan description … The claims procedures do not preclude …
[2] eCFR · 29 CFR 2560.503-1 · § 2560.503-1(f)(2)(i), (f)(2)(iii)(A)-(B), (h)(3)(i) · checked 2026-11-06
not later than 72 hours after receipt of the claim by the plan … not later than 15 days after receipt of the claim by the plan … not later than 30 days after receipt of the claim. This period may be extended one time by the plan for up to 15 days … (3) Group health plans. … (i) Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determ…

How we found this

We matched your question to 2 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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