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:
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.
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.”
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:
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.
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:
You must file your appeal:
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.
Insurer continues to deny your claim
Your insurer must make a decision on the appeal:
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.
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:
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.
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.
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.
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:
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
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:
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:
Your insurer must accept this decision.
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.
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.
A standard external review is decided as soon as possible, but no later than sixty days after the receipt of your request.
If you believe your situation is urgent, you may ask for an expedited (fast) review.
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.
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).
To request an external review:
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: