Appeals

Health Insurance and your rights

If your health insurer refuses to cover a procedure, pay a claim or ends your coverage, you have the right to ask them to reconsider their decision.

• They're required to do so in a timely manner. This is called an appeal.

Under the Affordable Care Act, you have much stronger rights to appeal decisions made by health plans that began on or after September 23, 2010. Grandfathered plans are exempt.

• Insurers have to tell you why they've denied your claim or ended your coverage. And they have to let you know how you can dispute their decisions.

The first step in the appeals process is usually to file an Internal Appeal and later, if necessary, to file what's called an External Appeal or External Review.

In some less common cases, such as when an emergency decision is needed, an internal and external appeal can be filed at the same time.

♦ Don't give up after a denial. Studies show almost no one appeals, even though many people who do win. Insurance companies count on you not bothering.

• You have the right to ask your insurer for a free copy of your claim file and the medical guidelines they used to deny it.

• If you have Medicare, Medicare Advantage or Medicaid, the appeal rules are different. See our Medicare Advantage Appeals Process page.

Internal Appeals

The internal appeals process guarantees a place where you can present information your health plan might not have known about, giving families a straightforward way to clear up misunderstandings.

Health plans beginning on or after September 23, 2010 must have an internal appeals process that:

• Allows consumers to appeal when a health plan denies a claim for a covered service or rescinds coverage

• Gives consumers detailed information about the grounds for the denial of claims or coverage

• Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process

• Ensures a full and fair review of the denial

• Provides consumers with an expedited appeals process in urgent cases

There are 3 steps in the internal appeals process

♦ You file a claim

A claim is a request for coverage or payment.

• The most common problem is when the insurer doesn't pay the claim the way the plan's benefits summary says it should.

This is where knowing your benefits comes in.

Calling or submitting an appeal online is often enough to point out this mistake and get the claim reprocessed correctly.

♦ Your health plan denies the claim

Your insurer must notify you in writing and explain why.

Most of the time this is either a coding issue, or treatment details weren't included with the claim.

• Your health care provider will usually refile a claim, especially if the claim is large.

Your insurer has to tell you its decision on a claim:

• Within 15 days if you're seeking prior authorization for a treatment

• Within 30 days for medical services you already received

• Within 72 hours for urgent care cases

♦ You file an internal appeal for denial of service or denied payment

To file an internal appeal, you need to:

• Complete all forms required by your health insurer. Or you can write to your insurer with your name, claim number and health insurance ID number.

• Submit any additional information you want the insurer to consider, such as a letter from your doctor.

If your state has a Consumer Assistance Program, it may be able to help you file an appeal.

♦ You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.

If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal.

If your insurance company still denies your claim, you can file for an external review.

What papers do I need?

Keep copies of all information related to your claim and the denial. This includes information your insurance company gives you and information you give your insurance company, like:

• The Explanation of Benefits forms or letters showing what payment or services were denied

• A copy of the request for an internal appeal that you sent to your insurance company

• Any documents with additional information you sent to the insurance company (like a letter or other information from your doctor)

• A copy of any letter or form you're required to sign, if you choose to have your doctor or anyone else file an appeal for you

• Notes and dates from any phone conversations you have with your insurance company or your doctor about your appeal. Include the day, time, name and title of the person you talked to, and details about the conversation.

♦ Keep your original documents and send copies to your insurance company. The one exception: send the signed original of your appeal request, and of any form letting someone else (like your doctor) appeal for you. Keep copies of those for yourself.

Making your case

► Generally, to get a medicine, treatment plan or other service covered through the exceptions process, your doctor must help you make a case based on how appropriate it is for your medical condition.

♦ Points to emphasize may include one or more of the following:

• All other medicines covered by the plan haven't worked, or won't work as well as the medicine you're asking for.

• Any alternative drug covered by your plan has caused, or is likely to cause, side effects that may be harmful to you.

♦ If there's a limit on the number of doses you're allowed:

• The allowed dosage hasn't worked for your condition, or

• The drug likely won't work for you at that dose because of your physical or mental makeup. For example, based on your body weight, you may need more doses than your plan allows.

♦ If there's a limit on the number of treatments you can receive:

• The allowed number hasn't worked for your condition, or

• An explanation of why you need more treatments to recover completely, and what might happen if you don't receive them.

If a procedure is denied, the same argument needs to be made. Why is this procedure the best option for your condition?

What kinds of denials can be appealed?

You can file an internal appeal if your health plan won't provide or pay some or all of the cost for health care services you believe should be covered.

The plan might issue a denial because:

• The benefit isn't offered under your health plan

• Your medical problem began before you joined the plan (this is rare now. Most plans can't deny for pre-existing conditions, but grandfathered plans and short-term plans still can)

• You received health services from a health provider or facility that isn't in your plan's approved network

• The requested service or treatment is "not medically necessary"

• The requested service or treatment is an "experimental" or "investigative" treatment

• You're no longer enrolled or eligible to be enrolled in the health plan

How long does an internal appeal take?

• Your internal appeal must be completed within 30 days if your appeal is for a service you haven't received yet.

• Your internal appeal must be completed within 60 days if your appeal is for a service you've already received.

• At the end of the internal appeals process, your insurance company must give you a written decision.

If your insurance company still denies you the service or payment for a service, you can ask for an external review.

The insurance company's final decision must tell you how to ask for an external review.

What if my care is urgent and I need a faster decision?

In urgent situations, you can request an external review even if you haven't finished all of your health plan's internal appeals process.

You can file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function.

You may file an internal appeal and an external review request at the same time.

A final decision about an urgent appeal must come as quickly as your medical condition requires, and no later than 72 hours after your request is received.

This final decision can be given over the phone, but it must be followed by a written notice within 48 hours.