Appealing a health plan decision

Internal appeals

1. You file a claim: A claim is a request for coverage. You or a health care provider will usually file a claim to be reimbursed for the costs of treatment or services.
2. Your health plan denies the claim: Your insurer must notify you in writing and explain why:
   • 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
3. You file an internal appeal: 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.

What papers do I need?

• 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.

What kinds of denials can be appealed?

• 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
• It is revoking or canceling your coverage going back to the date you enrolled because the insurance company claims that you gave false or incomplete information when you applied for coverage

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?