What is an appeal?
- An appeal is a request to have the insurance company take a new look at a denial of benefits. This can be a medical denial (for example, a denial for health care treatment based on your diagnosis, care or treatment) or a non-medical denial (for example, something that the insurance company says is excluded in your contract).
How do I file an appeal?
- Your first step is to contact the insurance company. It is possible that the denial is an error and can be corrected over the phone.
- If the issue isn’t corrected by contacting the company, and you still believe the claim should be covered, look at your denial letter, summary of benefits or policy for information about the appeals process, and to whom you should send your appeal.
- Most insurance companies request that you file your appeal in writing within 180 days of the denial unless you have a good reason for the delay. If your insurance company states that your appeal is too late, contact the Bureau of Insurance.
What are the steps in the appeal process?
- Reconsideration: This may also be called a “Peer to Peer Review”. It is requested by your doctor and must be completed by the insurance company within one day of receiving the request.
- First Level Appeal: A first level appeal involves a review of your denial by one or more insurance company personnel. Your insurance company has 30 days from the date it receives your appeal to send you a decision letter.
- As a part of the appeal, you have the right to:
- Review your claim file
- Present evidence as a part of the appeals process
- Receive, free of charge, any new or additional evidence used by the insurance company in connection with your claim.
- Second Level Appeal: A second level appeal involves the review of your denial by a panel of insurance company personnel, but not those involved in the first appeal.
- You may ask for a hearing as a part of the second level appeal, and you and your physician may appear in person or participate by telephone.
- Your insurance company has 30 days from the date it receives your appeal to send a decision letter when no hearing is held, and 45 days when a hearing is held.
If your second level appeal is denied, you may qualify for an independent external review. Please contact the Bureau for more information.
You may file a complaint with the Bureau of Insurance at any time. The Bureau’s investigation and your company appeals are separate.
Appealing a denied medical claim
An external review is an additional step in the appeals process after the insurance company denies paying your health insurance claim. The review is done by an independent review organization (IRO).
How do I qualify for an external review?
If you have appealed a claim to your health insurance company and still think they are wrong to have denied the claim, or have processed it incorrectly, you may be able to request an external review, if you meet the following conditions:
- Complete internal appeals first. You must have already completed the internal appeals process with the company. Usually the process includes two levels of appeals.
- Request a review within 12 months of appeal decision. You must request an external review within 12 months of receiving a final decision on your appeal.
- Employee plans must be “fully funded.” If your plan is through your employer, it must be “fully funded,” versus “self-funded.” Your human resources department can tell you which type you have. (Note, some “trusts” and self-funded plans still qualify for review. Contact the Bureau with any questions.)
- Specific grounds for complaint. To qualify for external review, your complaint has to involve one of the following:
- Medical Necessity: Services or products a health care practitioner provides to prevent, diagnose, or treat an illness, injury or disease. (Occasionally, an issue may be deemed medically necessary but is not covered in the policy, which would mean it does not qualify for external review.)
- Pre-existing Conditions: Health conditions that you may or may not have when you start coverage under a new insurance policy.
- Experimental or Investigational: Treatment is determined to be scientifically unproven by insurance company standards.
- Medical Diagnosis, Care or Treatment
Request for Independent External Appeal of a Denied Medical Claim
If you have other questions related to external review, please review the Bureau’s Guide to Requesting an Independent External Review for Health Insurance (PDF) or contact our Public Health Nurse Consultant Violet Hyatt at (207) 624-8459. An external review application is available on-line.