Appealing Health Plan Decisions

The Affordable Care Act ensures your right to appeal health insurance plan decisions--to ask that your plan reconsider its decision to deny payment for a service or treatment. New rules that apply to health plans created after March 23, 2010 spell out how your plan must handle your appeal (usually called an “internal appeal”). If your plan still denies payment after considering your appeal, the law permits you to have an independent review organization decide whether to uphold or overturn the plan’s decision. This final check is often referred to as an “external review.”

Your state may have a health care Consumer Assistance Program that can help you file an appeal or request a review.

What This Means for You

• When an insurance plan denies payment for a treatment or service, you can request an appeal. When your plan receives your request it is required to review its own decision. For plan years or policy years beginning on or after July 1, 2011, when your plan denies a claim, it is required to notify you of:
  • The reason your claim was denied.
  • Your right to file an internal appeal.
  • Your right to request an external review if your internal appeal was unsuccessful.
  • The availability of a Consumer Assistance Program (when your state has one).
    
• If you don’t speak English, you may be entitled to receive appeals information in your native language upon request. This right applies to plan years or policy years beginning on or after January 1, 2012.

• When you request an internal appeal, your plan must give you its decision within:
  • 72 hours after receiving your request when you’re appealing the denial of a claim for urgent care. (If your appeal concerns urgent care, you may be able to have the internal appeal and external review take place at the same time.)
  • 30 days for denials of non-urgent care you have not yet received.
  • 60 days for denials of services you have already received.

• If after internal appeal the plan still denies your request for payment or services, you can ask for an independent external review. For plan years or policy years that begin on or after July 1, 2011, your plan must include information on your denial notice about how to request this review. If your state has a Consumer Assistance Program, that program can help you with this request.
• If the external reviewer overturns your insurer’s denial, your insurer must give you the payments or services you requested in your claim.

Some Important Details

• The parts of the Affordable Care Act that concern internal appeals and external reviews apply only to health plans or policies that were created or purchased after March 23, 2010. Plans created on or before March 23, 2010, may be “grandfathered health plans.” The appeals and review rights do not apply to them.
• Your internal appeals rights in the health care reform law take effect when your plan starts a new plan year or policy year on or after September 23, 2010.
• Your external review rights will take effect by January 1, 2012. Some states already have an external review process that meets the new rules.
• How much these new rules will change your current appeal rights depends on the state you live in and the type of plan you have. Some group plans may require more than one level of internal appeal before you’re allowed to submit a request for an external review. However, all levels of the internal appeals process must be completed within the timelines above.

For More Information

• Learn how the external review process works.
• If you have questions about whether the internal appeals and external review provisions apply to you, ask your health plan or state insurance regulator.
• Your state may have a health care Consumer Assistance Program that can help you file an appeal or request a review.
• Find detailed technical and regulatory information on appealing health plan decisions.
• Learn about other consumer protections in the new law.