Paul Sanchez
Appealing an insurance decision can be a daunting but often successful task. The process varies depending on the type of insurance and the reason for denial, but there are some common elements across all health plans. For instance, the first step in the process typically involves contacting the insurance company and requesting that they reconsider the denial. This may involve a peer-to-peer insurance review where your doctor challenges the decision. If the first appeal is unsuccessful, the request may be escalated to a medical director at the insurance company. If internal appeals are exhausted, an external review by an independent organization may be requested. This step involves an independent reviewer with the insurance company and a doctor assessing the appeal. Consumers have the right to appeal health plan decisions to deny payment of claims to an outside, independent review organization, regardless of their state of residence.
| Characteristics | Values |
|---|---|
| When to appeal | When your claim is denied, or when your coverage is revoked or cancelled |
| Who can appeal | You can appeal yourself, or you can authorise another person (such as a doctor, attorney, parent, or spouse) to represent you |
| How to appeal | Contact your insurer to understand the process, keep records of all interactions, submit any supporting documentation, and follow the specified timeframe |
| Internal appeal | The first step in the appeals process, involving a review by employees not involved in the original decision, with a final decision provided in writing |
| External appeal | If you disagree with the outcome of the internal appeal, you can request an external review by an independent third party, which may be expedited in urgent situations |
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What You'll Learn
Internal appeals
If your insurance claim has been denied, you may be able to get the claim paid by following your insurer's internal appeals process. The denial notice you receive will outline the process you must follow, including how long you have to submit your internal appeal. Typically, you must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.
The internal appeals process typically involves the following steps:
- Contact your health insurer: Call your health insurer if you need clarification on how to submit an internal appeal. Ask them to conduct a full and fair review of their initial decision.
- Submit the required forms and documentation: Complete all forms required by your health insurer. You may also need to submit additional documentation or information for your insurer to consider, such as letters or reports from your doctor.
- Keep detailed records: Maintain detailed records of all communication and documentation related to your appeal. This includes keeping copies of letters, forms, and notes from phone conversations with your insurer or healthcare provider.
- Adhere to timelines: Pay close attention to the timelines specified in the denial notice. Submit your internal appeal within the required timeframe, which may vary depending on whether the denial is for a pre-service or post-service claim.
If you complete your health insurer's internal appeal process and still disagree with their decision, you may have the option to proceed with an external appeal. This involves taking your appeal to an independent third party for review, giving them the final say over whether your claim should be paid.
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External appeals
An external appeal is a request to an independent third party to review your insurance company's decision. This means that the insurance company no longer has the final say over whether to pay a claim.
You can file an external appeal if you have completed your health insurer's internal appeal process and still disagree with its decision. In Michigan, you can file an external appeal with DIFS using an online form or a paper form. In New York, you can file an appeal to the Department of Financial Services (DFS).
To file an external appeal, you must submit a written request within four months of receiving a notice or final determination from your insurer that your claim has been denied. If you need care immediately, you may be able to file an expedited external appeal, which will be decided within 72 hours.
The external appeal process is handled by an independent review organization, which may charge a fee of up to $25 per review. The external reviewer will issue a final decision, either upholding the insurer's decision or ruling in your favour. The insurer is required by law to accept the external reviewer's decision.
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Deadlines and timing
The first step in the appeals process is typically to initiate an internal appeal with your insurance company. Deadlines for internal appeals can vary depending on the nature of the service and the urgency of the situation. For example, if you are appealing a decision regarding a service you have not yet received, the deadline for the internal appeal is generally 30 days from receiving notice of the claim denial. On the other hand, if you are appealing a decision about a service you have already received, the deadline for the internal appeal is often extended to 60 days. In urgent health situations, some insurers may be required to expedite their decision-making process, sometimes within 72 hours.
It is important to carefully review the denial letter or notice from your insurance company, as it should include detailed information about the reasons for the denial, as well as the specific deadlines and procedures for initiating an appeal. Each insurance company may have its own unique appeals process, so understanding their requirements is crucial.
If your internal appeal is unsuccessful, you may have the option to pursue an external review. An external review involves seeking an independent third-party review of your appeal. Deadlines for external reviews can vary, but they typically need to be filed within a certain timeframe after the final adverse determination from your insurance company. For example, in some states, the deadline for filing an external appeal is 127 days from the date of the final adverse determination.
Throughout the appeals process, it is important to keep detailed records and copies of all relevant documentation, including correspondence with your insurance company, denial notices, appeal forms, and any supporting information or letters from medical professionals. These records can be crucial in supporting your appeal and ensuring that you meet all the necessary deadlines and requirements.
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Required documentation
When appealing an insurance decision, there are several types of documentation you may need to provide, depending on the specifics of your case. Here is a detailed guide to the required documentation for each stage of the appeals process:
Internal Appeal:
Firstly, you must submit an internal appeal to your insurance company, requesting them to conduct a full and fair review of their initial decision. The denial notice you receive from your insurer should outline the process for submitting an internal appeal, including any required documentation and the relevant deadlines. Make sure to carefully follow these instructions and provide all the requested information.
External Appeal (DIFS):
If you disagree with the outcome of your internal appeal, you can initiate an external appeal with an independent third party, such as DIFS (Department of Insurance and Financial Services). This process removes the insurance company's final say over whether to pay a claim. You can file an external appeal using an online form or a paper form (PDF). The required documentation for this stage includes:
- A copy of the final denial from your health insurer.
- A clear statement of the reason(s) why you are appealing the decision.
- Any additional documentation or evidence that supports your appeal. This could include medical records, expert opinions, or other relevant information that strengthens your case.
Expedited External Appeal:
In cases where immediate medical care is necessary to protect your life, health, or ability to regain maximum function, you may be eligible for an expedited external appeal. This process is conducted within 72 hours of your request. Along with the standard external appeal documentation, you must include a letter from your treating physician verifying the urgency of an expedited review. It's important to note that expedited external appeals are only applicable for pre-service denials and cannot be requested for post-service denials.
It's always a good idea to carefully review the requirements and guidelines provided by your insurance company and the relevant regulatory bodies to ensure you have all the necessary documentation for a successful appeal.
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Getting help with your appeal
Appealing an insurance decision can be a complicated and frustrating process, but there are resources available to help. Here are some steps to guide you through the process:
Understand the reason for the denial
Call your insurance company to understand why your claim was denied. Ask if it was due to a billing error, missing information, or another reason. Request that they walk you through the appeals process or provide you with written information on how to proceed. Keep detailed records of your conversations, including the names of representatives and any decisions made.
Gather supporting documentation
Collect and organize all relevant documentation to support your appeal. This includes Explanation of Benefits forms, letters outlining denied services or payments, records of any interactions with your insurance company, and any additional information from your doctor or other healthcare providers. Keep both the original documents and copies for your files.
Seek assistance from healthcare providers
Ask your doctor's office to send a letter to your insurance company explaining the medical necessity of the treatment or service. Ensure this letter is sent to the correct address listed in your plan's appeals process, and obtain a copy for your records. If applicable, verify that any required drug authorization forms have been completed by the prescribing physician. Consider requesting a peer-to-peer review between your healthcare provider and an insurance company doctor to discuss the necessity of the service or treatment.
Involve authorized representatives
You may choose to authorize a representative, such as a doctor, attorney, parent, or spouse, to assist you in the appeal process. This can be done by completing the appropriate sections of the internal and/or external appeal forms. They can help gather documentation, communicate with the insurance company, and guide you through the process.
Explore external resources
Look into external resources that can provide guidance and support during your appeal. Your state may have a Consumer Assistance Program that can answer questions and help you navigate the process. If your insurance is provided through your employer, contact the human resources or benefits department for information on how to proceed. Additionally, you can reach out to organizations like the Immune Deficiency Foundation for resources and assistance specific to your situation.
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Frequently asked questions
The first step is to contact your insurance company and request that they reconsider the denial. You may be able to request an internal appeal, which must be filed within a certain timeframe. If this is unsuccessful, you may be eligible for an external review by an independent organisation.
You will need to include copies of all correspondence with the insurer, a statement explaining why you believe the insurer's decision is wrong, and any documents that support your position.
An external review is conducted by an independent reviewer with the insurance company and a doctor with the same speciality as your doctor. They will assess your appeal and determine whether to approve or deny coverage. The decision of the external review is legally binding.
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