Appealing an Insurance Company’s Decision

triage-cancer-blog-appealsOne of the more frustrating aspects of cancer treatment is dealing with the insurance industry.  We pay our monthly premiums with the expectation that when and if the time comes, we will receive coverage for our medical care.  Sadly, it’s not always as turn-key as that.  Sometimes, claims are denied or we are charged more than we think we should be paying under our policies.  At that point we have to fight for our coverage.  This process is called an appeal (note: some companies call this a grievance).  There is an internal appeals process and an external appeals process.

Internal Appeals

Your insurer must notify you in writing if they deny your claim for coverage:

  • Within 15 days if you are seeking prior authorization for a treatment
  • Within 30 days for medical services already received
  • Within 72 hours for urgent care that you have not yet received

If you disagree with a decision your health plan has made, you have the right to file one of two types of internal appeals:

  1. Expedited Appeal

An expedited, or urgent appeal is filed if you have not received any treatment yet, or if you are in the middle of treatment and you or your doctor believe that your condition could involve imminent or serious threat to your health.  Obviously, this is an urgent matter, so your health plan should respond to your appeal within 72 hours of getting a qualifying appeal.  They will notify you by phone, as well as in writing.

  1. Standard Appeal

If your situation does not meet the standard for an expedited appeal, you still have the right to an appeal.  This process is longer, as your health plan will inform you of their decision, in writing, within 30 calendar days from the date they receive an appeal.

In both cases, your appeal will be reviewed by the appropriate administrative and/or clinical specialist.  These specialists will not have been involved in the initial decision or a subordinate of the person who made the initial decision.

What to Include in Your Appeal?

When preparing your appeal, but sure to include all the necessary information.  This means the member name and ID number, the name of the provider who will or has provided the care, the dates of service, the claim reference number for the specific decision you are appealing, and the precise reason you disagree with the initial decision.  You have the right to include any documents, comments or other materials that are relevant to your appeal.

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 ask for an external appeal at the same time as your internal appeal.

If your insurance company denies your internal appeal, you can file for an external appeal.

External Appeals

Under the Affordable Care Act (ACA) and some state laws, you not only have the right to appeal a decision within your insurance plan, but you also have the right to ask for an external review.  This means that an external, independent, specialist will review your appeal and the insurance plan no longer has final say over whether to pay a claim.  Keep in mind, you can ask for an external review if your internal appeal was denied or was not satisfactorily resolved within the 30 days or 72 hours, in cases of an expedited appeal.

All states are required to participate in an external review process that meets the consumer protection standards of the ACA. Your state may also have an external review process that is more protective. In California, which has some the strongest consumer protections in the county, this means going to http://hmohelp.ca.gov.  To find out about the external review process in your state, visit: http://triagecancer.org/resources/stateresources/.

If your state doesn’t have an external review process that meets the minimum consumer protection standards, the U.S. Department of Health and Human Services (HHS) will oversee your state’s external review process for health insurance companies. If your state relies on an HSA-administered external review, you can begin that process in four ways:

  1. Call 1-888-866-6205 to request an external review request form. Then fax an external review request to: 1-888-866-6190.
  2. Mail an external review request form to: MAXIMUS Federal Services 3750 Monroe Avenue, Suite 705 Pittsford, NY 14534
  3. Submit a request via email: is ferp@maximus.com
  4. At some point in the near future you will be able to request an external review online at externalappeal.com

Ideally, you will not need any of this information.  However, if you do, take heart.  Thanks to the ACA, there are strong consumer protections available in every state and we see an average of approximately 50% of external appeals of denials get successfully overturned.

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