Health Insurance Denials and Appeals

Health Insurance Denials and Appeals

Receiving a denial for a service or treatment from your insurance company can leave you with many questions. The good news is every insurer has a process by which you can ask them to reconsider their decision to deny coverage, called an appeal.

When Coverage is Denied

Denials are issued if your plan does not cover the service or treatment you or your provider requested and/or if your plan determines that the care is not medically necessary.

By law, the health plan must provide written notification:

  • Within 15 days for prior authorization requests
  • Within 30 days of treatment
  • Within 72 hours for urgent cases

What to Do Next

When appealing a denial of coverage, you will need to work closely with your care team to ensure all required documentation is submitted.

Here are some basic steps you and your care center may take when coverage is denied:

Learn More About the Denial

If a health plan denies payment for a service, under the Affordable Care Act the health plan is required to provide:

  • The reason the claim was denied
  • Information on the right to file an internal appeal
  • Guidance on the right to request an external review
  • Contact information for any state Consumer Assistance Program (if available)

If the health plan denies a pre-service claim or a prior authorization, the insurer will communicate the decision verbally to the medical provider and follow-up with letters to both the patient and provider.

If the health plan denies a post-service claim, the patient will be notified via mail with an Explanation of Benefits (EOB).

File an Internal Appeal

An internal appeal is the formal process of requesting that a health plan reconsider, via a full and fair review, a coverage decision to deny payment for a service.

It’s important to note you have a limited amount of time to file an appeal. Department of Labor regulations require the filing of a standard appeal within 180 days of receipt of the denial letter. Once an internal appeal is filed, the health plan may:

  • Overturn the initial claim denial
  • Uphold the initial claim denial

In most cases, a member can request a second level appeal. For individual and fully-insured plans, the next level is often an external review. For self-funded group plans, the next level might be an additional internal level.

File an External Appeal

An external appeal is a reconsideration of a health plan’s coverage denial decision by an outside, independent organization. The external review is conducted by an impartial expert who is not a direct employee of, or related to, the health plan. If the case is urgent, it is recommended that one file an external review request at the same time as the internal appeal.

In most states, a written request for an external review must be filed within 60 days of the date the health plan sent a decision.

The external review may either:

  • Overturn the health plan’s decision
  • Uphold the health plan’s decision

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