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 are required to do so in a timely manner. This is called an appeal.

Under the Affordable Care Act, consumers have much stronger rights to appeal decisions made by health plans created after March 23, 2010.

• 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 is 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.

Internal Appeals

The internal appeals process will guarantee a venue where consumers may present information their health plan might not have been aware of, giving families a straightforward way to clear up misunderstandings.

Under the new rules, new 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; and

• 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 often and most common claim is one where the insurer did not pay the claim in accordance with the plan's benefits summary.

This is where knowing your benefits comes in.

Calling or submitting an appeal online is often sufficient 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 were not included with the claim submission.

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

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

Within 30 days for medical services 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 that you want the insurer to consider, such as a letter from the doctor.

The Consumer Assistance Program in your state can file an appeal for you.

♦ 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 provides to you and information you provide to 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 that relate to 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 submit copies to your insurance company.

You’ll need to send your insurance company the original request for an internal appeal and your request to have a third party (like your doctor) file your internal appeal for you.

Make sure to you keep your own copies of these documents.

► Generally, to get a medicine, treatment plan or other service covered through the exceptions process, your doctor must help you make a case for the exception based upon the appropriateness for your medical condition.

♦ Points to emphasize may be based on one or more of the following:

All other medicines covered by the plan have not been or won’t be as effective as the medicine you are 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:

That the allowed dosage hasn’t worked for your condition, or

The drug likely won’t work for you based on your physical or mental makeup. For example, based on your body weight, you may need to take more doses than what’s allowed by your plan.

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

That 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 do not receive more treatments.

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

• 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 appeals 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 provide you with 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 determination 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 completed all of the health plan’s internal appeals processes.

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 your appeal must come as quickly as your medical condition requires, and at least within 4 business days after your request is received.

This final decision can be delivered verbally, but must be followed by a written notice within 48 hours.