There are 3 steps in the internal appeals process:
You file a claim: A claim is a request for coverage. You or a health care provider will typically file a claim to be reimbursed for the costs of treatment or services.
Your health plan denies the claim: Your insurer must notify you in writing and explain why:
- within 15 days if seeking prior authorization for treatment
- within 30 days for medical services already received
- within 72 hours for urgent care
- within 72 hours for urgent care cases
File an internal appeal: To file an internal appeal, you must:
fill out all forms required by your health insurer. or you can write to your insurer with your name, claim number, and health insurance identification number.
send any additional information you want the insurer to consider, such as a letter from your doctor.
Your state’s consumer assistance program can file an appeal for you.
You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, you can request an external review at the same time as your internal appeal.
If your insurance company continues to deny your claim, you can request an external review.
what papers do I need?
Keep copies of all information related to your claim and the denial. this includes information provided to you by your insurance company and information you provide to your insurance company such as:
- explanation of benefits forms or letters showing what payment or services were denied
- a copy of the internal appeal request you sent to your insurance company
- any documents with additional information you have sent to the insurance company (such as a letter or other information from your doctor)
- a copy of any letter or form you are required to sign, if you choose to have your doctor or any someone else files an appeal for you.
- notes and dates of any phone conversations you have with your insurance company or doctor related to your appeal. Include the day, time, name and title of the person you spoke with, and details of the conversation.
- Keep your original documents and send copies to your insurance company. You will need to send your original request for an internal appeal and your request to have a third party (such as your doctor) file your internal appeal for you to your insurance company. be sure to keep your own copies of these documents.
what types of denials can be appealed?
You can file an internal appeal if your health plan doesn’t provide or pay part or all of the cost of health care services that you think should be covered. the plan might issue a denial because:
- Your health plan does not offer the benefit
- Your medical problem began before you joined the plan
- You received health services from a provider or health center that is not is in your plan’s approved network
- the requested service or treatment is “not medically necessary”
- the requested service or treatment is an “experimental” or “investigational” treatment
- no longer enrolled or eligible to be enrolled in the health plan
- revokes or cancels your coverage from the date you enrolled because the insurance company claims you provided false information. 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 have not yet received.
- Your internal appeals must be completed within 60 days if your appeal is for a service you have 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 a service or payment for a service, you can request an external review. the insurance company’s final determination should tell you how to request an external review.
what if my care is urgent and I need a quicker decision?
In urgent situations, you may request an external review even if you have not completed all of the health plan’s internal appeal processes. You may file an expedited appeal if the timeframe for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function. You can file an internal appeal and a request for external review at the same time.
The final decision on your appeal should come as quickly as your medical condition requires and at least within 4 business days of receiving your request. this final decision may be delivered orally, but must be followed up with written notice within 48 hours.