{
 "cite": {
  "title": "The federal appeal rights that force a reasoned answer to a denied claim",
  "url": "https://denialfacts.com/how-to-appeal",
  "publisher": "Axion Labs — Denial Facts",
  "checked": "2026-09-05",
  "dataset": {
   "version": "2026-09-05",
   "fixity": "sha256-70fcef553523e50058a299023fafac57763341dfadc1bbd86b956b6fe1079dd3"
  },
  "source": {
   "name": "CMS Transparency in Coverage Public Use File (PY2026 release, PY2024 claims), data.healthcare.gov",
   "url": "https://data.healthcare.gov/"
  },
  "rule": "29 CFR 2560.503-1",
  "license": "free to quote with the URL",
  "receipt": null
 },
 "attribution": {
  "source": "Denial Facts (https://denialfacts.com)",
  "license": "Free to use with attribution and a link to https://denialfacts.com"
 },
 "checked": "2026-08-26",
 "note": "Per-insurer appeal PROCEDURE facts, brand-level, quoted verbatim from each insurer's own published policy pages. Applied to every CMS state entity whose name matches the brand. Audience labels matter: a provider-policy fact is not a member-appeal fact, and the render must never blur the two. Federal member-appeal timeframes (180-day internal, 4-month external review, deemed exhaustion) are published separately by this site and apply regardless of insurer. 2026-08-26: member-side second sources added for the seven brands that were provider-only (cigna, unitedhealthcare, aetna, anthem, bcbs-alabama, centene-ambetter, florida-blue); every quote fetched from the insurer's own domain that day.",
 "brands": {
  "cigna": {
   "brand": "Cigna Healthcare",
   "match": [
    "cigna"
   ],
   "sources": [
    {
     "id": "provider-appeals",
     "title": "Appeals and Disputes Policy and Procedures",
     "url": "https://www.cigna.com/health-care-providers/coverage-and-claims/appeals-disputes",
     "audience": "health care providers",
     "checked": "2026-08-25"
    },
    {
     "id": "member-appeals",
     "title": "Health Care Appeals & Grievances (member guide, undated page)",
     "url": "https://www.cigna.com/individuals-families/member-guide/appeals-grievances",
     "audience": "members",
     "checked": "2026-08-26"
    }
   ],
   "routing": {
    "source_id": "provider-appeals",
    "what_it_shows": "Cigna's own table of which denial scenarios are appealed by the CUSTOMER (the patient) and which by the HEALTH CARE PROVIDER. Most patients never learn this split — appealing a denial that only your provider has standing to appeal wastes the window.",
    "rows": [
     {
      "scenario": "Precertification (authorization) denial (for services not yet rendered)",
      "path": "Customer appeal"
     },
     {
      "scenario": "Precertification (authorization) not obtained – services denied",
      "path": "Health care provider appeal"
     },
     {
      "scenario": "Claim reimbursement denial (including mutually exclusive, incidental, or bundling denials)",
      "path": "Health care provider appeal"
     },
     {
      "scenario": "Experimental or investigational procedure denial",
      "path": "Either"
     },
     {
      "scenario": "Benefit denials (e.g., exclusion, limitation, administration [e.g., copay, deductible, etc.])",
      "path": "Customer appeal"
     },
     {
      "scenario": "Maximum reimbursable amount",
      "path": "Customer appeal"
     },
     {
      "scenario": "Inpatient facility denial (e.g., level of care, length of stay, delayed treatment day)",
      "path": "Either"
     },
     {
      "scenario": "Medical necessity denial",
      "path": "Either"
     }
    ]
   },
   "facts": [
    {
     "label": "Provider appeal filing window",
     "value": "180 calendar days",
     "quote": "within 180 calendar days of the date of the initial payment or denial notice",
     "source_id": "provider-appeals",
     "note": "Provider-side window. The member's own internal-appeal right is at least 180 days under federal law (29 CFR 2560.503-1(h)(3)(i)) independently of this policy."
    },
    {
     "label": "Arbitration as final step, provider disputes",
     "value": "within one year of the final internal decision letter",
     "quote": "you must request arbitration within one year of the date of the letter communicating the final internal level review decision",
     "source_id": "provider-appeals",
     "note": "Applies to provider payment/termination disputes, not to a member's external review right."
    },
    {
     "label": "Reconsideration route for coding-edit denials",
     "value": "CignaforHCP.com or Provider.Evernorth.com",
     "quote": "a CignaforHCP.com or Provider.Evernorth.com user with claims/reconsideration access can submit a reconsideration request on the claim",
     "source_id": "provider-appeals",
     "note": "Provider portal route — a patient cannot use it, but can ask their provider's billing office to."
    },
    {
     "label": "Appeal mailing addresses vary by ID-card indicator",
     "value": "GWH-Cigna/'G' cards: PO Box 188062, Chattanooga, TN 37422 · all other appeals: PO Box 188011, Chattanooga, TN 37422",
     "quote": "GWH-Cigna or 'G' indicators: PO Box 188062, Chattanooga, TN 37422 … All other appeals: PO Box 188011, Chattanooga, TN 37422",
     "source_id": "provider-appeals",
     "note": "The ID card decides the address. Sending an appeal to the wrong PO box costs days inside a fixed window."
    },
    {
     "label": "Member appeal filing window",
     "value": "180 calendar days",
     "quote": "within 180 calendar days of the date of the initial payment or denial notice",
     "source_id": "member-appeals",
     "note": "Member-side confirmation: same 180-day window Cigna publishes on the provider side, here stated to members. File by phone (number on the ID card) or via the myCigna Forms Center."
    },
    {
     "label": "Member appeal decision clocks",
     "value": "30 days medical-necessity appeals / 60 days post-service administrative",
     "quote": "within 30 calendar days for Pre Service and Post Service Medical Necessity appeals, and within 60 days for Post Service Administrative appeals",
     "source_id": "member-appeals"
    },
    {
     "label": "External review is binding on Cigna",
     "value": "independent external reviewer, medical-judgment appeals",
     "quote": "you or your representative may have the option to submit the dispute for resolution (which is binding upon Cigna Healthcare and the plan) by an independent external reviewer for appeals that involve medical judgment",
     "source_id": "member-appeals",
     "note": "Availability depends on plan type — self-insured employer plans may not offer it."
    }
   ]
  },
  "unitedhealthcare": {
   "brand": "UnitedHealthcare",
   "match": [
    "unitedhealthcare",
    "united healthcare",
    "unitedhealth"
   ],
   "sources": [
    {
     "id": "provider-appeals",
     "title": "Pre- and post-service appeals and reconsiderations",
     "url": "https://www.uhcprovider.com/en/claims-payments-billing/appeals.html",
     "audience": "health care providers",
     "checked": "2026-08-25"
    },
    {
     "id": "member-form",
     "title": "Member service request form (memberforms.uhc.com — carries state-specific sections incl. California IMR; undated)",
     "url": "https://memberforms.uhc.com/Memberappealsandgrievances.html",
     "audience": "members",
     "checked": "2026-08-26"
    }
   ],
   "routing": {
    "source_id": "provider-appeals",
    "what_it_shows": "UnitedHealthcare runs a mandatory TWO-STEP provider process — a claim reconsideration first, an appeal only after — and is strict about who counts as the member's representative.",
    "rows": [
     {
      "scenario": "Post-service claim dispute (provider)",
      "path": "Reconsideration first, then appeal — both steps inside 12 months"
     },
     {
      "scenario": "Pre-service denial",
      "path": "Appeal 'made prior to a planned health care service'; expedited available if delay could seriously jeopardize the member"
     },
     {
      "scenario": "Provider appealing on the member's behalf",
      "path": "Requires authorization/patient consent — an assignment of benefits is NOT enough"
     }
    ]
   },
   "facts": [
    {
     "label": "Combined window for both steps",
     "value": "12 months",
     "quote": "You have 12 months to complete the following steps: Step 1: File a claim reconsideration request. Step 2: File an appeal if you disagree with the outcome of the claim reconsideration decision.",
     "source_id": "provider-appeals",
     "note": "One clock covers both steps — a slow reconsideration eats the appeal window."
    },
    {
     "label": "Two-step structure is mandatory",
     "value": "reconsideration, then appeal",
     "quote": "you must submit a claim reconsideration request. If you don't agree with the outcome of the reconsideration, you may submit an appeal",
     "source_id": "provider-appeals"
    },
    {
     "label": "Assignment of benefits is not representation",
     "value": "separate patient consent needed",
     "quote": "an assignment of benefits does not constitute designation of an authorized representative",
     "source_id": "provider-appeals",
     "note": "For patients: your provider billing UnitedHealthcare for you does NOT automatically let them appeal AS you — a separate authorization is needed, or you appeal yourself."
    },
    {
     "label": "Submission is portal/API",
     "value": "UnitedHealthcare Provider Portal or API",
     "quote": "You can use either the UnitedHealthcare Provider Portal or an API … to submit a post-service appeal.",
     "source_id": "provider-appeals",
     "note": "No mailing address or fax is published on this page."
    },
    {
     "label": "Expedited appeal is pre-service only",
     "value": "not available after the service",
     "quote": "If you have already provided the service, an expedited or urgent appeal is not available.",
     "source_id": "provider-appeals"
    },
    {
     "label": "Peer-to-peer review windows",
     "value": "3 business days inpatient / 21 calendar days outpatient",
     "quote": "Inpatient cases must be submitted within 3 business days and outpatient cases within 21 calendar days from posted denial.",
     "source_id": "provider-appeals"
    },
    {
     "label": "Member filing window",
     "value": "180 calendar days",
     "quote": "within 180 calendar days following any incident or action that is the subject of your dissatisfaction",
     "source_id": "member-form",
     "note": "Member-side second source. UnitedHealthcare's provider page publishes no member window; this member form states 180 days."
    },
    {
     "label": "Who may appeal (member side)",
     "value": "member, authorized representative, or contracted provider",
     "quote": "a timely request by a member, an authorized representative or a contracted provider to change a plan denial decision",
     "source_id": "member-form"
    },
    {
     "label": "Member review clocks",
     "value": "acknowledge 5 days, decide 30 days standard / 3 days urgent",
     "quote": "acknowledge receipt within 5 calendar days and provide an answer within 30 calendar days for a standard review. If your problem is urgent, UnitedHealthcare must give you a decision within 3 calendar days.",
     "source_id": "member-form",
     "note": "Stated on a form page that also carries California-specific sections (DMHC 1-888-466-2219, Independent Medical Review) — plan-state specifics can vary."
    }
   ]
  },
  "aetna": {
   "brand": "Aetna",
   "match": [
    "aetna"
   ],
   "sources": [
    {
     "id": "dispute-process",
     "title": "Dispute & Appeals Process (Aetna process as published by Banner|Aetna; aetna.com's own overview page blocks automated readers)",
     "url": "https://www.banneraetna.com/en/health-care-professionals/dispute-and-appeals-overview/dispute-and-appeals-process.html",
     "audience": "health care providers",
     "checked": "2026-08-25"
    },
    {
     "id": "member-claim-denials",
     "title": "Claim denial resources for members (aetna.com, undated page; fetched via browser — aetna.com blocks automated readers)",
     "url": "https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html",
     "audience": "members",
     "checked": "2026-08-26"
    }
   ],
   "routing": {
    "source_id": "dispute-process",
    "what_it_shows": "Aetna splits disputes into a reconsideration step and an appeal step, and reserves the member appeal process for pre-service and concurrent medical-necessity decisions.",
    "rows": [
     {
      "scenario": "Claims payment dispute (reimbursement, coding)",
      "path": "Provider reconsideration, then provider appeal"
     },
     {
      "scenario": "Pre-service or concurrent medical necessity decision",
      "path": "Member appeal process"
     }
    ]
   },
   "facts": [
    {
     "label": "Dispute filing window",
     "value": "180 days from the initial decision",
     "quote": "You have 180 days from the date of the initial decision to submit a dispute.",
     "source_id": "dispute-process",
     "note": "State law can extend it: 'To the extent that our policy varies from the applicable laws or regulations of an individual state, the requirements of the state regulation supersede our policy.'"
    },
    {
     "label": "Appeal decision timeframe",
     "value": "60 calendar days",
     "quote": "We will notify you of our appeal decision in writing within 60 calendar days of our receipt of the appeal.",
     "source_id": "dispute-process"
    },
    {
     "label": "Two-level structure",
     "value": "reconsideration, then appeal",
     "quote": "Following reconsideration, if the decision is not in your favor, you may initiate an appeal.",
     "source_id": "dispute-process"
    },
    {
     "label": "Submission routes",
     "value": "provider portal, the PO box on the EOB, or fax",
     "quote": "Write to the P.O. box listed on the EOB statement … Fax the request to 1-866-455-8650",
     "source_id": "dispute-process",
     "note": "The EOB in hand carries the correct address — there is no single national PO box."
    },
    {
     "label": "Member appeal scope",
     "value": "pre-service and concurrent medical-necessity decisions",
     "quote": "The member appeal process applies to appeals related to pre-service or concurrent medical necessity decisions.",
     "source_id": "dispute-process"
    },
    {
     "label": "Member appeal filing window",
     "value": "180 days from the denial notice",
     "quote": "You have 180 days to appeal from when you get notice of the denied claim, unless your plan brochure (or Summary Plan Description) gives you more time.",
     "source_id": "member-claim-denials",
     "note": "Member-side second source, on Aetna's own domain. Same page confirms the provider dispute window: 'Providers usually have 180 days after a claim denial to submit a dispute.'"
    },
    {
     "label": "Member submission routes",
     "value": "phone (number on ID card) or mail to the address on the EOB",
     "quote": "Phone: Call Aetna® Member Services at the number on your member ID card. Mail: Send your appeal to the address on your EOB. Or print and mail our form.",
     "source_id": "member-claim-denials"
    },
    {
     "label": "Second-level review window (two-appeal plans)",
     "value": "60 days from the appeal decision letter",
     "quote": "You can ask for a second review within 60 days from the date of the appeal decision letter.",
     "source_id": "member-claim-denials",
     "note": "Member decision clocks differ by plan design: one-appeal plans decide in 30 days pre-care / 60 days otherwise; two-appeal plans in 15 / 30. Urgent: 72 hours (one-appeal) or 36 hours (two-appeal). The provider source's flat 60-day clock is the provider process, not this one."
    }
   ]
  },
  "anthem": {
   "brand": "Anthem (Elevance Health)",
   "match": [
    "anthem",
    "healthkeepers"
   ],
   "sources": [
    {
     "id": "va-manual",
     "title": "Provider manual excerpt — claim payment disputes (Anthem HealthKeepers Plus, Virginia)",
     "url": "https://providers.anthem.com/docs/gpp/VA_PU_ManualExcerptClaimPaymentDisputes.pdf",
     "audience": "health care providers (Virginia Medicaid plan)",
     "checked": "2026-08-25"
    },
    {
     "id": "va-member-appeals",
     "title": "Grievances and appeals — member page (Anthem HealthKeepers Plus, Virginia Medicaid; undated page)",
     "url": "https://www.anthem.com/va/medicaid/complaints-grievances",
     "audience": "members (Virginia Medicaid plan)",
     "checked": "2026-08-26"
    }
   ],
   "routing": {
    "source_id": "va-manual",
    "what_it_shows": "THE structural fact about Anthem: there is no single national procedure. Each state entity publishes its own process on its own state page (providers.anthem.com/{state}-provider). The Virginia HealthKeepers Plus manual below is one documented example — your own state's page and your denial letter govern.",
    "rows": [
     {
      "scenario": "Claim payment dispute (finalized claim, provider disagrees)",
      "path": "Provider reconsideration, then provider appeal — 'no action is required by the member'"
     },
     {
      "scenario": "Pre-service denial of a service (no claim yet)",
      "path": "Medical necessity appeal — a separate process from payment disputes"
     }
    ]
   },
   "facts": [
    {
     "label": "Reconsideration window (VA example)",
     "value": "365 calendar days from the EOP",
     "quote": "within 365 calendar days from the date on the EOP … Reconsiderations filed more than 365 days from the EOP will be considered untimely",
     "source_id": "va-manual"
    },
    {
     "label": "Appeal window (VA example)",
     "value": "15 months of the date of service or 180 days from the reconsideration decision",
     "quote": "Claim payment appeals received more than 15 months of the date of service or 180 calendar days of the date you are notified of the [reconsideration decision are untimely]",
     "source_id": "va-manual"
    },
    {
     "label": "Resolution clocks (VA example)",
     "value": "reconsideration ~30 days (+30 extension), appeal ~60 days (+60 extension)",
     "quote": "30 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 30 additional calendar days.",
     "source_id": "va-manual"
    },
    {
     "label": "Submission routes (VA example)",
     "value": "Availity Payment Appeal Tool, or by mail",
     "quote": "Availity Payment Appeal Tool at availity.com … Written (for reconsiderations and claim payment appeals): Mail all required [items to] P.O. Box 61599",
     "source_id": "va-manual"
    },
    {
     "label": "One reconsideration per claim",
     "value": "single shot at step one",
     "quote": "Providers are only allowed one claim payment reconsideration per claim.",
     "source_id": "va-manual"
    },
    {
     "label": "Member appeal window (VA example)",
     "value": "60 days from the denial",
     "quote": "You can appeal within 60 days if your service gets denied",
     "source_id": "va-member-appeals",
     "note": "Member-side second source for the same Virginia HealthKeepers Plus plan as the provider manual. Medicaid member windows are short — 60 days here vs the 180-day commercial norm. No conflict with the provider-side 365-day reconsideration window: different audience, different clock."
    },
    {
     "label": "Member submission routes (VA example)",
     "value": "portal/Sydney Health app, phone 800-901-0020 (TTY 711), fax 855-832-7294, or mail",
     "quote": "Please send your written request by mail to: Grievance and Appeals Department, HealthKeepers, Inc., P.O. Box 62429, Virginia Beach, VA 23464",
     "source_id": "va-member-appeals"
    },
    {
     "label": "Representative needs written consent",
     "value": "friend, family member, doctor, or attorney — with written consent",
     "quote": "To appoint a representative to act on your behalf, please provide your written consent. Your representative can be a friend or family member, your doctor, or an attorney.",
     "source_id": "va-member-appeals"
    }
   ]
  },
  "bcbs-alabama": {
   "brand": "Blue Cross and Blue Shield of Alabama",
   "match": [
    "blue cross and blue shield of alabama"
   ],
   "sources": [
    {
     "id": "provider-appeal-qa",
     "title": "Provider Internal Post-Service Claim Appeal Process — Questions & Answers (PRV20198-2403)",
     "url": "https://providers.bcbsal.org/portal/documents/10226/306297/Provider+Internal+Post-Service+Claim+Appeal+Process+Q+and+A.pdf",
     "audience": "health care providers",
     "checked": "2026-08-25"
    },
    {
     "id": "member-appeal-form",
     "title": "Blue Cross and Blue Shield of Alabama Appeals — member appeal form L2073010 (MBR20193-1907)",
     "url": "https://www.bcbsal.org/rapidresponse/pdf/AL1/L-2073010.pdf",
     "audience": "members",
     "checked": "2026-08-26"
    }
   ],
   "routing": {
    "source_id": "provider-appeal-qa",
    "what_it_shows": "Blue Cross Blue Shield is a federation of independent licensees — every Blue plan publishes its own procedure, and the Alabama plan's is unusually explicit: providers get ONE internal appeal, and a provider appealing on the member's behalf is expressly excluded from the provider process.",
    "rows": [
     {
      "scenario": "Post-service claim dispute (payer allowance, medical necessity, coding, COB errors)",
      "path": "Provider appeal — one internal appeal only"
     },
     {
      "scenario": "Provider appeal on behalf of member",
      "path": "Excluded from the provider process — 'see member appeal process'"
     }
    ]
   },
   "facts": [
    {
     "label": "Appeal filing window",
     "value": "180 days from adjudication/denial",
     "quote": "Consideration will not be given to appeals received greater than 180 days from the claim adjudication/denial date.",
     "source_id": "provider-appeal-qa"
    },
    {
     "label": "One internal appeal, described as a courtesy",
     "value": "single internal appeal",
     "quote": "Blue Cross will perform a single internal appeal as a courtesy to the provider when there is an adverse benefit determination",
     "source_id": "provider-appeal-qa",
     "note": "After it, 'any subsequent appeal rights will be defined by his or her Participating or Preferred Provider Agreement or legal settlement in effect.'"
    },
    {
     "label": "Submission address and fax",
     "value": "PO Box 10408, Birmingham, AL 35202-0408 · Fax 205-220-9562",
     "quote": "Blue Cross and Blue Shield of Alabama Appeals, Post Office Box 10408, Birmingham, AL 35202-0408. Fax: 205-220-9562",
     "source_id": "provider-appeal-qa"
    },
    {
     "label": "A Customer Service review is not an appeal",
     "value": "formal form + provider signature required",
     "quote": "Is requesting a claims review through Customer Service the same as requesting an appeal? No.",
     "source_id": "provider-appeal-qa",
     "note": "Incomplete forms and letters will not be processed — the formality is load-bearing."
    },
    {
     "label": "Member appeal mailing address",
     "value": "Customer Service Appeals, P.O. Box 12185, Birmingham, AL 35202-2185",
     "quote": "Blue Cross and Blue Shield of Alabama, Attention: Customer Service Appeals, P.O. Box 12185, Birmingham, AL 35202-2185",
     "source_id": "member-appeal-form",
     "note": "DIFFERENT box from the provider appeal address (P.O. Box 10408). The audience decides the mailbox — a member appeal sent to the provider box is misrouted."
    },
    {
     "label": "Member right to appeal, booklet governs the deadline",
     "value": "right stated on the form; no filing window printed",
     "quote": "Your benefits plan provides you the right to appeal a benefit determination. … You may refer to your benefit booklet for complete information concerning your Appeals Rights.",
     "source_id": "member-appeal-form",
     "note": "The member form itself carries no deadline — the benefit booklet and denial letter govern. We publish only what the source states."
    },
    {
     "label": "Authorized representative route",
     "value": "call 1-800-292-8868, request form L2013011",
     "quote": "To appoint and Authorized Representative, please call 1-800-292-8868 and request the Authorized Representative form L2013011.",
     "source_id": "member-appeal-form",
     "note": "Typo ('and' for 'an') is in the original form."
    }
   ]
  },
  "kaiser": {
   "brand": "Kaiser Permanente",
   "match": [
    "kaiser"
   ],
   "sources": [
    {
     "id": "hi-member-guide",
     "title": "Member Grievances & Appeals Quick Reference Guide (Kaiser Permanente Hawaii, Medicaid/QUEST context)",
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/community-providers/hi/ever/member-grievances-appeals-quick-reference-guide.pdf",
     "audience": "members (Hawaii Medicaid plan)",
     "checked": "2026-08-25"
    }
   ],
   "routing": {
    "source_id": "hi-member-guide",
    "what_it_shows": "Kaiser is regional: each Kaiser Foundation Health Plan entity publishes its own process, and windows can be far SHORTER than the commercial 180-day norm — this member guide gives 30 days. The denial letter's own deadline governs.",
    "rows": [
     {
      "scenario": "Grievance (dissatisfaction, no benefit change)",
      "path": "Member — 'There is no time limit on filing a grievance.'"
     },
     {
      "scenario": "Appeal of an action",
      "path": "Member, or a provider/representative WITH the member's written consent"
     }
    ]
   },
   "facts": [
    {
     "label": "Appeal filing window (this plan)",
     "value": "30 days from the action",
     "quote": "Appeals must be received within 30 days from the action that is being appealed.",
     "source_id": "hi-member-guide",
     "note": "Materially shorter than the 180-day federal commercial norm — plan type decides, the denial letter governs."
    },
    {
     "label": "State hearing after Kaiser's decision",
     "value": "30 days to request",
     "quote": "The AAO has to get the letter within 30 days from receiving Kaiser Permanente's decision about the appeal.",
     "source_id": "hi-member-guide"
    },
    {
     "label": "Benefits can continue during appeal",
     "value": "if requested in time",
     "quote": "If Kaiser Permanente decided to reduce, delay or stop anything that was already approved, members have the right to receive benefits during the appeals process",
     "source_id": "hi-member-guide",
     "note": "If the final decision goes against the member, 'the member will have to pay for the services that were requested to be continued'."
    },
    {
     "label": "Representative needs written consent",
     "value": "provider or rep may file with consent",
     "quote": "A provider or authorized representative may file a grievance or an appeal on behalf of a member with written consent from the member.",
     "source_id": "hi-member-guide"
    }
   ]
  },
  "centene-ambetter": {
   "brand": "Ambetter (Centene)",
   "match": [
    "ambetter",
    "celtic insurance",
    "superior healthplan"
   ],
   "sources": [
    {
     "id": "tx-grievance-appeals",
     "title": "Grievance and Appeals (Ambetter from Superior HealthPlan, Texas)",
     "url": "https://www.ambetterhealth.com/en/tx/provider-resources/manuals-and-forms/grievance-appeals/",
     "audience": "health care providers (Texas plan page)",
     "checked": "2026-08-25"
    },
    {
     "id": "tx-member-guide",
     "title": "Appeals and Grievances Guide (Ambetter from Superior HealthPlan, Texas — member guide, last updated December 2024)",
     "url": "https://www.ambetterhealth.com/content/dam/centene/Sunshine/Ambetter/PDFs/AMB-TX-Appeals-Grievances-Guide.pdf",
     "audience": "members",
     "checked": "2026-08-26"
    }
   ],
   "routing": {
    "source_id": "tx-grievance-appeals",
    "what_it_shows": "Centene's Ambetter runs as state-branded plans (Superior, Sunshine, Peach State and others) — the process is published per state. Its sharpest rule: claim-payment disagreements are NOT appeals at all; they go through a separate claim dispute process first.",
    "rows": [
     {
      "scenario": "Medical necessity denial",
      "path": "Appeal — 180 calendar days"
     },
     {
      "scenario": "Claims payment disagreement",
      "path": "NOT an appeal: 'the provider must follow the process for claim reconsideration or claim dispute … prior to filing a Complaint.'"
     }
    ]
   },
   "facts": [
    {
     "label": "Medical-necessity appeal window",
     "value": "180 calendar days",
     "quote": "within one hundred and eighty (180) calendar days of receipt of a medical necessity denial",
     "source_id": "tx-grievance-appeals"
    },
    {
     "label": "Standard resolution clock",
     "value": "30 calendar days",
     "quote": "within thirty (30) calendar days of receipt of the complaint",
     "source_id": "tx-grievance-appeals"
    },
    {
     "label": "Expedited appeal clock",
     "value": "1 working day / 72 hours from complete information",
     "quote": "within one (1) working day or seventy-two (72) hours from the date all needed information is received",
     "source_id": "tx-grievance-appeals"
    },
    {
     "label": "Submission (Texas plan)",
     "value": "Complaints Department, 5900 E. Ben White Blvd., Austin, TX 78741 · Fax 1-866-683-5369",
     "quote": "Ambetter from Superior HealthPlan, Complaints Department, 5900 E. Ben White Blvd., Austin, TX 78741 … Fax: 1-866-683-5369",
     "source_id": "tx-grievance-appeals",
     "note": "Texas plan's address — each state plan publishes its own."
    },
    {
     "label": "Member appeal window",
     "value": "180 calendar days, orally or in writing",
     "quote": "A member has 180 calendar days from Ambetter's notice of adverse determination to file an appeal, either orally or in writing.",
     "source_id": "tx-member-guide",
     "note": "Member-side confirmation of the 180-day window; also confirms the 30-day resolution clock ('shall not exceed 30 calendar days from the date Ambetter receives the appeal') and the expedited 1-working-day / 72-hour-written clock."
    },
    {
     "label": "Member APPEALS address differs from the complaints address",
     "value": "Appeals Department, 5900 E Ben White Blvd., Austin, TX 78741 · Fax 1-866-918-2266",
     "quote": "Mail, email or fax all medical appeals and reconsiderations with supporting documentation to: Ambetter, Attn: Appeals Department, 5900 E Ben White Blvd., Austin, TX 78741 … Fax: 1-866-918-2266",
     "source_id": "tx-member-guide",
     "note": "Same street address as the Complaints Department but a different fax: appeals go to 1-866-918-2266, grievances/complaints to 1-866-683-5369. The plan page's complaints fax is not the appeals fax."
    },
    {
     "label": "External review via MAXIMUS",
     "value": "four months from the final internal decision; standard decided ≤45 days, expedited ≤72 hours",
     "quote": "The member or member's provider can request a standard External Review request through MAXIMUS within four (4) months after the date of the final internal appeal determination notice.",
     "source_id": "tx-member-guide",
     "note": "Route: Externalappeal.com, fax 1-888-866-6190, or mail to MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534. Matches the federal 4-month right this site publishes."
    }
   ]
  },
  "molina": {
   "brand": "Molina Healthcare",
   "match": [
    "molina"
   ],
   "sources": [
    {
     "id": "ia-member-appeals",
     "title": "Member Appeals & Grievances (Molina Healthcare of Iowa, Medicaid — hosted by Iowa HHS)",
     "url": "https://hhs.iowa.gov/media/12135/download",
     "audience": "members (Iowa Medicaid plan)",
     "checked": "2026-08-25"
    }
   ],
   "routing": {
    "source_id": "ia-member-appeals",
    "what_it_shows": "Molina's windows are set state-by-state in its Medicaid contracts and are often 60 days — far shorter than the 180-day commercial norm. Marketplace plans run on the federal 180-day right instead. The denial letter decides which world you are in.",
    "rows": [
     {
      "scenario": "Appeal of a denial (this Medicaid plan)",
      "path": "Member, approved representative, or provider — 60 calendar days"
     },
     {
      "scenario": "Unhappy with Molina's appeal decision",
      "path": "State Fair Hearing — 120 calendar days from Molina's decision letter"
     }
    ]
   },
   "facts": [
    {
     "label": "Appeal filing window (this plan)",
     "value": "60 calendar days",
     "quote": "You must send your appeal within 60 calendar days of the date of Molina's denial letter.",
     "source_id": "ia-member-appeals"
    },
    {
     "label": "Decision clock",
     "value": "30 calendar days standard, expedited available",
     "quote": "You will be notified of our decision within 30 calendar days for a standard appeal/grievance.",
     "source_id": "ia-member-appeals"
    },
    {
     "label": "State Fair Hearing window",
     "value": "120 calendar days",
     "quote": "You must send your request within 120 calendar days from the date on the letter from Molina notifying you of our decision.",
     "source_id": "ia-member-appeals"
    }
   ]
  },
  "florida-blue": {
   "brand": "Florida Blue (Blue Cross and Blue Shield of Florida)",
   "match": [
    "florida blue",
    "blue cross and blue shield of florida",
    "health options"
   ],
   "sources": [
    {
     "id": "provider-manual",
     "title": "Provider Manual — Care, COB, Appeals, Quality (GuideWell/Florida Blue)",
     "url": "https://assets.guidewell.com/m/4622654dd8a24153/original/providers-provider-manual-03.pdf",
     "audience": "health care providers",
     "checked": "2026-08-25"
    },
    {
     "id": "member-appeal-form",
     "title": "Health Plan Grievance and Appeal Form — member form 63343 0517R (non-HMO)",
     "url": "https://files.guidewell.com/m/5ea6e374d12e2fce/original/member-forms-grievance-appeal-non-hmo-eng.pdf",
     "audience": "members",
     "checked": "2026-08-26"
    }
   ],
   "routing": {
    "source_id": "provider-manual",
    "what_it_shows": "Florida Blue's published decision clocks split by claim type: pre-service grievances/appeals decided in 30 days, post-service in 60, urgent in 72 hours — and the reviewer is guaranteed independent of the original decision-maker.",
    "rows": [
     {
      "scenario": "Pre-service claim grievance/appeal",
      "path": "Member — decision within 30 calendar days"
     },
     {
      "scenario": "Post-service claim grievance/appeal",
      "path": "Member — decision within 60 calendar days"
     },
     {
      "scenario": "Medicare Advantage denial, non-participating provider",
      "path": "Provider — written appeal within 60 days of remittance advice, with a Waiver of Liability"
     }
    ]
   },
   "facts": [
    {
     "label": "Decision clocks by claim type",
     "value": "30 days pre-service / 60 days post-service / 72 hours urgent",
     "quote": "If the grievance or appeal involves a pre-service claim, our decision regarding the grievance or appeal will be made within 30 calendar days of receipt of the grievance or appeal. For post-service claims and other grievances, our decision will be made within 60 calendar days",
     "source_id": "provider-manual"
    },
    {
     "label": "Independent reviewer guaranteed",
     "value": "not the original decision-maker",
     "quote": "[the reviewer will be] neither the individual who made the initial adverse determination nor be a subordinate of such individual",
     "source_id": "provider-manual"
    },
    {
     "label": "MA non-participating provider appeal",
     "value": "60 days from remittance advice",
     "quote": "You may file your appeal in writing within 60 calendar days after the date of the remittance advice.",
     "source_id": "provider-manual"
    },
    {
     "label": "Member FILING window not stated in this manual",
     "value": "the denial letter/EOB governs",
     "quote": "",
     "source_id": "provider-manual",
     "note": "This manual states Florida Blue's decision clocks, not the member's filing deadline. The federal floor (generally 180 days for commercial internal appeals) applies; the number printed on the denial letter or EOB is the authority. We publish only what the source actually says."
    },
    {
     "label": "Member appeal mailing address",
     "value": "Florida Blue Health Plan Appeals, P.O. Box 44197, Jacksonville, FL 32231-4197",
     "quote": "Mail to: Florida Blue Health Plan Appeals, P.O. Box 44197, Jacksonville, FL 32231-4197",
     "source_id": "member-appeal-form",
     "note": "Member-side second source (subscriber-signed form, linked from floridablue.com's Member Forms page). The form states no filing deadline either — consistent with our existing fact that the denial letter/EOB governs the member window."
    }
   ]
  },
  "hcsc": {
   "brand": "HCSC Blues (BCBS of Texas, Illinois, Oklahoma, New Mexico, Montana)",
   "match": [
    "blue cross and blue shield of texas",
    "blue cross blue shield of texas",
    "blue cross and blue shield of illinois",
    "blue cross blue shield of illinois",
    "blue cross and blue shield of oklahoma",
    "blue cross blue shield of oklahoma",
    "blue cross and blue shield of new mexico",
    "blue cross blue shield of new mexico",
    "blue cross and blue shield of montana",
    "blue cross blue shield of montana",
    "hcsc"
   ],
   "sources": [
    {
     "id": "member-blog",
     "title": "What to Do if Your Claim Is Not Approved (BCBS of Texas member guidance)",
     "url": "https://connect.bcbstx.com/understanding-benefits/b/weblog/posts/claim-not-approved",
     "audience": "members",
     "checked": "2026-08-25"
    }
   ],
   "routing": {
    "source_id": "member-blog",
    "what_it_shows": "The clearest member-side statement among the majors: who may appeal, the 180-day window, and the exact external-review handoff. HCSC operates the Blues in five states; this is Texas's member guidance and the pattern is HCSC-wide, but the denial letter governs.",
    "rows": [
     {
      "scenario": "Claim not approved",
      "path": "Member — 'You, your doctor or another person you've named to represent you can appeal.'"
     },
     {
      "scenario": "Internal appeal denied",
      "path": "External review — four months from the internal decision notice"
     }
    ]
   },
   "facts": [
    {
     "label": "Member appeal filing window",
     "value": "180 days",
     "quote": "You have 180 days to file an appeal from the date the claim wasn't approved.",
     "source_id": "member-blog"
    },
    {
     "label": "Review clocks",
     "value": "~30 days pre-approval appeals, up to 60 days others",
     "quote": "A standard appeal takes about 30 days for review for getting care pre-approved. Other appeals may take up to 60 days.",
     "source_id": "member-blog"
    },
    {
     "label": "Urgent review",
     "value": "72 hours",
     "quote": "If you qualify for urgent review, the outside review organization will give you a decision within 72 hours.",
     "source_id": "member-blog"
    },
    {
     "label": "External review window",
     "value": "four months from the internal decision notice",
     "quote": "You have four months from the date of your internal review decision notice to file a request for external review.",
     "source_id": "member-blog",
     "note": "Matches the federal 4-month right this site publishes — here in the insurer's own words."
    },
    {
     "label": "Submission",
     "value": "phone or mail",
     "quote": "You can appeal by phone or by mail.",
     "source_id": "member-blog"
    }
   ]
  }
 }
}