Appeal Route Wizard

Last reviewed October 17, 2026

Written by Aptiva Health Editorial Team · Reviewed by Taylor Sorrels, Esq. and Crystal Brake, RCM Director · Editorial & review standards · How we research

Appeal Route Wizard

Answer five quick questions. You’ll get the appeal route for your kind of plan, the deadlines, the forms and a checklist.

Everything you type stays in your browser. Nothing is sent or saved.

Question 1 of 5: Which state do you live in?

Kentucky Indiana Another state

Question 2 of 5: What kind of coverage denied the claim?

Plan from an insurer (fully insured or ACA Marketplace) Self-funded employer plan (ERISA) Medicare Advantage Original (Traditional) Medicare Medicaid managed care plan Workers' compensation Auto insurance (PIP / medical payments) I’m not sure

Question 3 of 5: What reason does the denial letter give?

Not medically necessary No prior authorization Out of network Experimental or investigational Coding or billing error Benefit limit reached I’m not sure

Question 4 of 5: Could waiting seriously harm your health?

Yes — my clinician says it is urgent No I’m not sure

Question 5 of 5: What care was denied?

MRI Physical therapy Epidural steroid injection Something else

Next Show my route

Different plans follow different appeal rules. The Appeal Route Wizard asks five questions and shows the route that usually applies to a plan like yours.

How to use the Appeal Route Wizard

1. Pick your state. Choose Kentucky, Indiana or another state.
2. Pick your plan type. Choose fully insured or ACA plan, self-funded employer plan, Medicare Advantage, Original Medicare, Medicaid managed care, workers’ comp, auto/PIP, or “not sure.”
3. Pick the denial type. Use the reason on your letter. The Denial Decoder can help if the wording is unclear.
4. Say how urgent it is. Tell the tool whether waiting could seriously harm your health.
5. Pick the procedure. Choose MRI, physical therapy, epidural steroid injection or other.
6. Read your route. See the steps, deadlines, forms, a checklist and links to guides.

How to tell which plan type you have

Plan type matters most. Many large employers pay claims themselves. These are self-funded plans. They generally use the federal external review process, not the state one (29 CFR 2590.715-2719(c)). Plans an employer buys from an insurance company are fully insured, and state rules apply to them. Not sure? Ask your HR department, or call the number on your insurance card and ask, “Is my plan fully insured or self-funded?” You can also pick “not sure” in the wizard.

What your results mean

Your result shows the usual steps for your plan type. Here are some examples of what it may show.

Fully insured or ACA plan, Kentucky. First an internal appeal with your plan, then independent external review, requested through your insurer. Your insurer completes form HIPMC-IRE-6, and you sign a medical records release (KY DOI Form HIPMC-IRE-6). Most plans must allow at least 180 days for the internal appeal and 4 months to ask for external review (KY DOI UM Review Guide (2026)).

Fully insured plan, Indiana. Indiana has two internal levels. First a grievance, then an appeal of the grievance decision, which must be resolved within 45 days (IC 27-8-28-17). After that, you can ask for an external review through your insurer within 120 days (IC 27-8-29-13). Indiana has no state form, so your insurer supplies its own instructions.

Self-funded employer plan. At least 180 days to file an internal appeal (29 CFR 2560.503-1(h)(3)(i)), then 4 months to ask for federal external review (45 CFR 147.136(d)).

Medicare Advantage. Ask your plan to reconsider within 65 days from the date on the notice (Medicare.gov).

Original Medicare. Ask for a redetermination within 120 days of getting your notice (Medicare.gov).

Medicaid managed care. Appeal to the plan within 60 calendar days from the date on the notice (42 CFR 438.402).

Workers’ comp and auto/PIP. These follow separate state steps. The result links to the Kentucky or Indiana guide.

Your answer about urgency matters because urgent cases often have faster, expedited review. Your checklist is built for your procedure, with links to guides for an MRI, physical therapy or an epidural steroid injection.

Where the deadlines and rules come from

The routes come from federal claims and external review rules, Medicare.gov, and federal Medicaid rules. State routes come from Kentucky statutes and the Kentucky Department of Insurance, and from the Indiana Code and the Indiana Department of Insurance. Each source is linked above and listed on this page.

What this tool can’t do

• It can’t see your plan documents, which may give you more time or extra steps.
• It can’t confirm your plan type. Only your plan or employer can.
• It can’t tell you whether to appeal or whether you will win.
• It does not cover every program. The Indiana Department of Insurance, for example, says self-funded plans, Medicaid, Medicare and workers’ comp are outside its authority (IDOI: Jurisdiction).

Your privacy

Your answers stay in your browser. Nothing is sent to Aptiva or saved. If you choose the optional “email me” feature, only your email address, state, plan type and the tool name are sent.

Frequently asked questions

What if I pick “not sure” for plan type?

Your result will be less specific. Use the tips under “How to tell which plan type you have” to find out, then run the wizard again.

Does Kentucky’s process apply to my self-funded plan?

Usually not. Kentucky’s appeal rights apply to fully insured plans issued in Kentucky (KY DOI: Appealing a Denial). Self-funded plans generally use the federal process.

Why does Indiana show an extra step?

Indiana law has a second internal level: an appeal of the grievance decision (IC 27-8-28-17).

What happens after I see my route?

Use the Appeal Deadline Calculator to turn your letter date into real dates.

Where can I read the whole process?

See the Coverage & Appeals Center.

Sources

• 29 CFR 2560.503-1 — Claims procedure (eCFR)
• 45 CFR 147.136 — Internal claims and appeals and external review (eCFR)
• 29 CFR 2590.715-2719 — External review for group health plans (eCFR)
• Medicare.gov — Appeals in Medicare health plans
• Medicare.gov — Appeals in Original Medicare
• 42 CFR 438.402 — Medicaid managed care appeals (eCFR)
• KRS 304.17A-623 — External review (Kentucky Legislature)
• KY DOI — Utilization Management Review Guide (rev. January 2026)
• KY DOI — Form HIPMC-IRE-6, External Review Information Face Sheet
• KY DOI — Appealing a Denial From Your Health Benefit Plan (Expanded Version)
• Indiana Code Title 27 (IC 27-8-28, IC 27-8-29)
• IDOI — Internal and External Grievance Procedures
• IDOI — Jurisdiction of the IDOI