Who should an employee call about a claim they do not understand?
Start with the member services number on the back of the insurance card, which can explain how the claim was processed. If it still does not make sense, the employee should call their benefits contact, who can look at the plan documents and the explanation of benefits.
What is behind the short answer.
The short answer is above. These are the details that decide it for a specific plan.
The carrier first
Member services can explain how a claim was processed, what was applied to the deductible and why a charge was denied or reduced.
Then the benefits contact
A benefits advisor can compare the claim against the plan documents and help decide whether to appeal or dispute it.
Keep the paperwork
The explanation of benefits, the provider bill and any call notes make a dispute much easier to resolve.
Do not wait
Appeals and disputes have deadlines. The sooner the employee asks, the more options remain.
What the rules say.
The figures and requirements below come from the federal sources cited at the end of this section. General information, not legal advice.
At least 180 days to appeal
For group health plans, a claimant must have at least 180 days after notice of a denial to file an appeal.
The plan has a deadline to decide
On a plan with one level of appeal, the decision is due within 30 days for a pre-service claim and 60 days for a post-service claim. Plans with two levels have shorter limits for each.
External review is available
Plans subject to the federal rules must offer independent external review. A request is due within four months of the final denial, and a standard decision is due within 45 days.
Urgent situations move faster
An expedited external review decision is due within 72 hours when the standard timeline would seriously jeopardize the patient health.
Sources: 29 CFR 2560.503-1
How a Michigan employee can challenge a denial.
Michigan runs a free state external review for insured coverage. Employer plans that are self-funded generally follow the federal process instead, so it helps to know which kind of plan the employer has.
Start with the insurer
The insurer must decide an internal appeal within 30 days for care not yet received and within 60 days for care already provided.
Then the state, at no cost
If the insurer upholds the denial or does not answer in time, an employee can ask the Michigan Department of Insurance and Financial Services (DIFS) for an external review. DIFS does not charge for it.
The window is 127 days
An external review request goes to DIFS within 127 days of the insurer final decision, online or on the DIFS form, with a copy of the denial and supporting documents.
Urgent cases move faster
For an urgent denial of care not yet received, the employee asks the plan for an expedited review, then sends DIFS a request within 10 days of the plan final decision with a letter from the treating physician. DIFS completes it within 72 hours.
DIFS help line: 877-999-6442, Monday to Friday, 8 a.m. to 5 p.m. Sources: Michigan DIFS: appealing a denied claim | DIFS press release, June 2026
CFH clients send employees to us.
Our service team helps employees read claims, understand explanations of benefits and, where it makes sense, pursue an appeal.
Related pages.
Give Employees a Person to Call About Benefits
Employees should know who to call when a plan question comes up in March, not only in November.
Denied Claims and Appeals
What to do when a claim is denied and how appeals work.
Why did we get a bill after a visit that only had a copay?
Because the copay usually covers the visit itself and not everything billed around it.
Avoiding Group Health Insurance Plan Confusion
The full guide to helping employees understand their group health plan.
Questions that come up next.
Short answers to the questions employees ask after this one. Each links to its own page.
Does explaining the plan change what it covers?
No. Explanation does not change coverage. The plan documents, the carrier contract and the summary of benefits and coverage decide what is covered. What explanation changes is whether employees choose the plan that fits them and know how to use it.
What should employees see before open enrollment?
At minimum: the summary of benefits and coverage for each option, a plain definition of the key terms, a side-by-side of premium and likely cost, a way to check their doctors against the network, and a named person to ask.
What is the difference between a deductible and an out-of-pocket maximum?
The deductible is what an employee pays for covered care before the plan starts sharing the cost. The out-of-pocket maximum is the most the employee pays in a year for covered in-network care. One is where sharing begins, the other is where it ends.
Ready? Send us your renewal, or talk it through with someone first. No cost, no obligation.
General information about group health plan terms, not legal or tax advice. Plan-specific questions belong with the plan documents and the carrier.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents, two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
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