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The Center for Consumer Information & Insurance Oversight

 

Has Your Health Insurer Denied Payment for a Medical Service? You Have a Right to Appeal

The Affordable Care Act, the health care reform law passed in 2010, requires many health plans to meet basic standards regarding internal appeals and external review processes. An internal appeal is when you ask your insurance company to determine if its first decision to deny coverage was a correct one.  An external review happens if your insurance company determines that its decision to deny coverage was correct and you believe that decision was in error.  In an external review, you request that somebody outside the plan make a determination.  Consumers have the following rights:

  • Right to information about why a claim or coverage has been denied.  Health plans and insurance companies have to tell you why they’ve decided to deny a claim or chosen to end your coverage. They have to let you know how you can dispute decisions. 
  • Right to appeal to the insurance company.  If you’ve had a claim denied or had your health insurance coverage cancelled or rescinded back to the date you initially enrolled, you have the right to an internal appeals process. You may ask your insurance company to conduct a full and fair review of its decision.  If the case is urgent, your insurance company must speed up this process.
  • Right to an independent review.  In many cases, you may be able to resolve your problem during the internal appeals process with your insurer. But you have other options if you can’t work it out through the internal appeals process. You now have the right to take your appeal to an independent third-party for review of the insurer’s decision.  This is called “external review.”  External review means that the insurance company no longer gets the final say over many benefit decisions. It also means patients and doctors have more control over health care.

Here’s How It Works:

You have the right to dispute decisions made by your insurer to deny coverage or payment for a medical service. There are rules both you and your insurer must follow when you dispute such decisions, which are explained below.

Please note: If you have health coverage from a plan that existed on March 23, 2010, your plan may be considered a “grandfathered plan.”  These plans may not have to follow the same rules. Check with your insurer to find out whether your coverage is grandfathered.

Use the links below to learn more about appealing health plan decisions:

What are the steps in the appeals process?

Step 1: 
You file a claim 
(or your provider files one on your behalf)

A claim is any request for benefits coverage.

You or a health care provider will usually file a claim to be reimbursed for the costs of treatment or services after you have received these.

You or your health care provider may sometimes be required to file a claim before you receive a treatment or service. This type of claim is called “prior authorization.”

Step 2: 
If your health plan denies your claim

If your health care plan denies all or part of your claim it must notify you and explain why, in writing:

  • Within 15 days for prior authorization
  • Within 30 days for medical services already received
  • Within 72 hours for urgent care cases.

Your insurer must explain your right to appeal their decision.

If you request it, your insurer must provide all the information about your plan’s decision, such as the name of experts consulted.

Your insurer must print information on its denial notices including the name of any Consumer Assistance Program (CAP) in your state. This program can help you file an appeal.  If your state has a Consumer Assistance Program, you can find information on it at www.healthcare.gov/consumerhelp.

Step 3: 
You file an “internal appeal.” 

You file an appeal requesting that your insurer reconsider its decision to deny your claim.

To file an internal appeal:

  • Complete all forms required by your health insurer to request an internal appeal, or write to your insurer with your name, claim number, and health insurance ID number.  In this letter, make sure to say that you are appealing the insurer’s denial.
  • Submit any additional information that you want the insurer to consider, such as a letter from the doctor.
  • Your CAP can file this appeal for you.  If you need the help, be sure to call.

You must file your appeal:

  • Within 180 days (6 months) of receiving notice that your claim was denied. 
  • In writing, or, when your need for care is urgent, over the phone.

If you have employer-sponsored coverage, you may be required to file two internal appeals before requesting an external review. 

For urgent health situations, you may ask for an external review request at the same time as your internal appeal request.  See below for more information. 
 

Step 4: 
Issue is resolved

or 

Insurer continues to  deny your claim

Your insurer must make a decision on the appeal:

  • Within 30 days for prior authorization
  • Within 60 days for medical services already received
  • Within 72 hours in urgent care cases (or less, depending on the medical situation)
  • You have a right to see and respond to all information used in the internal appeal decision.

Starting in plan years that begin on or after January 1, 2012, if you live in a county where at least 10 percent of the population speaks the same non-English language, your insurer must say in its appeals notices how you can get these notices translated and any customer help it offers, in that language.  Notices will be translated upon request. 

Step 5: 
Consumer files an external review

If, at the end of the internal appeal process, your insurer continues to deny the requested benefits, you can seek an external review.   You may have as few as sixty days to file a request for external review.

The external review will be conducted by an impartial expert who is not a direct employee of or related to your health insurer, and will provide an independent review of the denied claim. 

If your situation is urgent, you may be able to file an external review at the same time as the internal appeal.

If your claim is not eligible for external review, you may still be able to get help with your dispute from your Consumer Assistance Program or your state’s Department of Insurance.

Step 6: Steps for requesting an external appeal

 

If your health plan or issuer participates in the HHS-administered federal external review process: 

  • Find an external review request form at http://www.externalappeal.com/Forms.aspx
  • Call Toll Free: 888-866-6205 to request an external review request form
  • Fax an external review request  to:  1-888-866-6190

           OR

  • Mail an external review request form to:

    MAXIMUS Federal Services
    3750 Monroe Avenue, Suite 705
    Pittsford, NY 14534  

OR

If your health plan does not participate in the HHS-Administered federal external review process, the health plan will tell you how to request external review.

Step 7:  
External review either upholds or overturns your insurer’s decision to deny payment.

 

Your insurer is required by law to accept the external reviewer’s decision. 

That means that when the reviewer says the insurer must pay your claim, your insurer must do so right away.

What is an internal appeal?

An internal appeal is the action you can take if you disagree with a decision made by your insurer not to cover or pay for medical care.  When you file an internal appeal, you are asking your insurer to reconsider its decision to deny this payment or service.

If you believe your situation is urgent, you may ask for an expedited (fast) review.

An urgent care situation is one in which your health may be in serious jeopardy, or you may be in danger of failing to regain maximum function, or, in your doctor’s opinion, you may have pain that can’t be controlled while you wait for the internal appeal decision.

If you appeal and your plan continues to deny the service or payment, you may have the right to ask for an external review by a qualified outside third party – meaning an organization that is not associated with the health plan.  If the external reviewer decides your medical service should have been covered, your insurer will have to pay the claim or authorize your care.

What papers do I need?

Keep copies of all information related to your claim and to the denial of that claim. This includes information that your insurer provides to you, as well as all the information you provide to your insurer such as:

  • 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 send to your insurer.
  •  Any documents with any additional information you send to the insurer (such as 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 (known as a “third party”) file an appeal for you.
  • Notes and dates from any phone conversations you have with your insurer or your doctor that relates to your internal appeal. Include the day, time, name and title of the person you talked to and details about the conversation.
  •  Keep your original documents for your records and submit copies to your insurer.   You’ll need to send to your insurer a copy of the original request for an internal appeal and your request to have a third party (such as your doctor) file your internal appeal for you.  Make sure to keep copies of these documents.

Tip: Download and print this tracking sheet to help you keep track of the phone calls, documents filed, and decisions related to an appeal: http://www.healthcare.gov/news/factsheets/2012/06/appeals06152012b.html 

What kinds of denials can be appealed?  

You can file an internal appeal to your health plan if it won’t provide or pay some or all of the cost for health care services that you believe should be covered. For example, the plan might issue a denial because:

  • The benefit you used or are seeking is partially denied or isn’t a “covered service” (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 (an “out-of-network” provider);
  • The requested service or treatment is “not medically necessary”;
  • The requested service or treatment is an “experimental” or “investigative” treatment;
  • You are no longer enrolled or eligible to be enrolled in the health plan; or
  • It is revoking, or cancelling your coverage going back to the date you enrolled, because the insurer claims that you gave false or incomplete information when you applied for coverage.  This action is often referred to as a rescission of coverage.

How long does an internal appeal take?

  • Once the insurer denies your claim, you have up to 180 days (6 months) to file your internal appeal. 
  • Your internal appeal must be completed within 30 days of your request if your appeal is for a pre-service claim.
  • Your internal appeals must be completed within 60 days of your request if your appeal is for a claim where you have already received the service.
  • At the end of the internal appeals process, your insurer must provide you with a written decision.  If your insurer continues to deny you the service or payment for a service, this written decision is called a “final internal adverse benefit determination.”  If your insurer denies your appeal, you may have the right to ask for an external review.  The final internal adverse benefit determination must tell you how to request an external review.

What is an external review or an external appeal?

An external review or external appeal is a review of your insurer’s denial by an organization that is independent of your insurer. 

An external review either:

  • Upholds your insurer’s decision or
  • Decides in your favor, by overturning all or some of your insurer’s decision. 

Your insurer must accept this decision.  

What are my rights in an external review?

Effective January 1, 2012, health insurance issuers in all states must participate in an external review process that meets minimum consumer protection standards outlined in the Affordable Care Act.  

Your state may have an external review process that meets or goes beyond these standards.  If so, health insurers in your state will follow your state’s external review processes, and you will get all of the protections outlined in that process.  

If your state doesn’t have an external review process that meets the federal minimum consumer protection standards, the federal government will oversee an external review process for health insurers in your state.  You’ll get all of the consumer protections outlined in the Affordable Care Act. 

 

To find out whether health insurers in your state follow a state run external review process or a federally-administered external review process, please go to: http://cciio.cms.gov/resources/files/external_appeals.html.  You can also look at the information on your Explanation of Benefits (EOB) or on the final denial of the internal  appeal by your health plan. It will give you the contact information for the organization that will handle your external review case.

 

Health insurers that follow a federally-administered external review process may choose to participate in an HHS-administered process or to contract with accredited independent review organizations to conduct external review requests on their behalf.  If you’re in an employer-sponsored health plan, you may not be eligible to participate in a State run external review process.  If your plan does not participate in a State or HHS-administered external review process, under the Affordable Care Act, your health plan must contract with accredited independent review organizations to conduct external reviews on their behalf.

When do I file for external review?

You must file a written request for an external appeal within sixty days of the date your health insurer or health plan sent you a final decision denying your services or your claim for payment; this notice is typically called a final internal adverse benefit determination.   However, some State processes or plans may allow you more than sixty days to file your request.  The notice sent to you by your health insurance issuer or health plan should tell you the timeframe in which you must make your request.

For urgent health situations, you may file an external review request at the same time you file for an internal appeal. 

What types of denials can go to external review?

  • Any denial that involves medical judgment (such as medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit) where you or your provider may disagree with the health insurance plan.
  • Any denial that involves a determination that a treatment is experimental or investigational.
  • Rescissions of coverage.  A rescission is an action by a health insurance issuer to retroactively cancel or discontinue health insurance coverage going back to the date you enrolled, based on the insurer’s claim that you gave false or incomplete information when you applied for coverage. 

How long does external review take?

A standard external review is decided as soon as possible, but no later than sixty days after the receipt of your request.

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

If you believe your situation is urgent, you may ask for an expedited (fast) review.

  • An urgent care situation is one in which your health may be in serious jeopardy, or you may be in danger of failing to regain maximum function, or if a final adverse benefit determination concerns the admission, availability of care, or continued stay in a health care facility for which you received emergency services and have not yet been discharged from that facility.

In urgent situations, you may request an external review even if you haven’t completed all of the health plan’s internal appeals processes.  You may file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life and your ability to regain maximum function.  And, you may file an internal appeal and an external review request at the same time. 

You may file an urgent external request verbally. 

How long does an expedited external review take?

A final decision about your appeal must come as quickly as your medical condition requires, and at least within four 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). 

If my health insurance issuer participates in the HHS-administered external review process, how do I request an external appeal?

To request an external review:

  • Call Toll Free: 888-866-6205 to request an external review request form
  • Fax an external review request  to:  1-888-866-6190

           OR

  • Mail an external review request form to:

    MAXIMUS Federal Services
    3750 Monroe Avenue, Suite 705
    Pittsford, NY 14534

OR

 

A web-based portal will be available for filing external review requests, claims information, and communication with the federal government’s contractor for the HHS-administered federal external review process.  This portal:

  • Will allow insurers to securely upload case file documents eliminating the need for hard-copy communication.
  • Will provide you with secure log-in access to website.
  • Will provide you with access to ongoing information about your external review request such as the date the review request was accepted for review and the expected date of completion.