How to appeal a Kaiser Permanente denial
Your appeal path depends on which kind of Kaiser Permanente plan you have. Find yours below — deadlines differ, and deadlines are everything.
Medicare Advantage
You have a Medicare plan run by a private insurer (an “MA” or “Part C” plan) — the card says Medicare Advantage, and the insurer is a company like UnitedHealthcare, Humana, or Aetna.
Level 1 — Plan reconsideration
File within 65 days. The plan must use a different reviewer; medical denials need a physician reviewer.
Level 2 — Independent Review Entity (automatic)
If the plan says no again, it MUST forward your case to an outside reviewer automatically. You do nothing.
Level 3 — Administrative Law Judge
60 days to request a hearing if the amount in dispute meets the threshold.
ACA / Marketplace Plans
You bought your plan on healthcare.gov or a state exchange, or you have an individual (non-employer) plan regulated by the Affordable Care Act.
Step 1 — Internal appeal
180 days to file. Plan decides in 30 days (pre-service) or 60 days (post-service); 72 hours if urgent.
Step 2 — External review
State or federal HHS process depending on your state. Independent, binding, 4 months to file.
In parallel — state insurance department complaint
Your state DOI takes consumer complaints and can pressure insurers on process violations.
Employer Plans (ERISA)
Your insurance comes through a private-sector job — yours or a family member's. Most working-age Americans with employer coverage are in an ERISA plan, even when a big-name insurer administers it.
Step 1 — Internal appeal
180 days to file. New decision-maker, no deference to the original denial, qualified medical reviewer for clinical denials.
Step 2 — External review
Independent review organization for medical-judgment denials. Binding on the plan. 4 months to file.
Step 3 — Federal court (ERISA § 502)
Lawsuit to recover benefits. The record you built in the internal appeal is usually the ONLY evidence the court sees — build it well.