Questions & answers · Health insurance
How long does my employer health plan have to decide my claim?
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)(i) View original ↗
In short
- A job plan has 72 hours for urgent claims.
- It has 15 days before care and 30 days after care.
- It can add 15 days one time, for reasons outside its control.
What this means
It depends on the type of claim [1][2][3]. For an urgent care claim, the plan must tell you its decision as soon as possible, and no later than 72 hours after it gets the claim [1]. If your urgent claim is missing information, the plan must tell you what is missing no later than 24 hours after it gets the claim. You get at least 48 hours to send it. Then the plan must decide no later than 48 hours after it gets the information, or after your time to send it ends, whichever comes first [1]. For a pre-service claim (approval before care), the plan must decide no later than 15 days after it gets the claim. It may extend one time by up to 15 days, but only for reasons beyond its control, and it must tell you before the first 15 days end [2]. For a post-service claim (care you already got), the plan must decide no later than 30 days after it gets the claim. It may extend one time by up to 15 days, under the same conditions [3]. These rules are for job-based group health plans [1][2][3].
Where this comes from (3)
[1] 29 CFR 2560.503-1 (eCFR (current as of 2026-11-02)) · § 2560.503-1(f)(2)(i) · checked 2026-11-05
In the case of a claim involving urgent care, the plan administrator shall notify the claimant of the plan's benefit determination … not later than 72 hours after receipt of the claim by the plan … not later than 24 hours after receipt of the claim by the plan, of the specific information necessary to complete the claim. The claimant shall be afforded a reasonable amount of time … but not less than 48 hours, to provi…
[2] 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
[3] 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 3 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.
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.
Related answers
- Original Medicare denied my claim. What are the appeal steps and deadlines?
- My health plan dropped my medication from its formulary. How do I get an exception?
- My marketplace plan denied an out-of-network specialist visit. Can I appeal?
- My health insurer (for example UnitedHealthcare) denied my in-network hospital claim. How do I appeal?
Answer id FED11. Spotted an error? Tell us.