Questions & answers · Health insurance
How long does an employer health plan have to decide a claim before or after care?
Health insuranceAppealChecked Nov 5, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-05 · Source: 29 CFR 2560.503-1 (eCFR (current as of 2026-11-02)) · § 2560.503-1(f)(2)(iii)(A) View original ↗
In short
- A job plan has 15 days to decide before care.
- It has 30 days after care.
- Each can add 15 days one time, for reasons outside the plan's control.
What this means
For pre-service claims, where approval is needed before care, a job-based health plan must decide within 15 days after receiving the claim [1]. The plan may extend this period by up to 15 days, but only if the plan administrator determines the extension is necessary due to matters beyond the plan’s control and notifies the claimant before the initial 15-day period ends [1].
For post-service claims, where care has already been received, the plan must decide within 30 days after receiving the claim [2]. The plan may extend this period by up to 15 days [2].
These timeframes apply to group health plans under federal regulations [1][2]. The rules differ based on whether the claim is for care before (pre-service) or after (post-service) it occurs [1][2]. Employers offering such plans must follow these deadlines to comply with federal requirements [1][2].
Where this comes from (2)
[1] 29 CFR 2560.503-1 (eCFR (current as of 2026-11-02)) · § 2560.503-1(f)(2)(iii)(A) · checked 2026-11-05
not later than 15 days after receipt of the claim by the plan. This period may be extended one time by the plan for up to 15 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, prior to the expiration of the initial 15-day period
[2] 29 CFR 2560.503-1 (eCFR (current as of 2026-11-02)) · § 2560.503-1(f)(2)(iii)(B) · checked 2026-11-05
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, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, prior to the expiration of the initial 30-day period
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 2026-11-05.
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.
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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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