Sadly, there are situations when health insurers deny or even end coverage for an individual. You are not stuck without options! Under the Affordable Care Act, you are granted the right to appeal these issues.
If your plan was created or modified in specific ways since March 23rd, 2010, you are eligible to appeal. An important note about this date is some plans may be “grandfathered in” from before this date, so the new rules may not be applicable.
An internal appeal is basically a request for the insurance company to perform a complete review of the action that you are appealing.
The basic process is as follows:
- File a medical claim.
- The claim is denied. This is given in writing and done in 30 days for healthcare treatments already performed, 15 days for authorization, and 72 hours for urgent care.
- File an internal appeal. You will need complete any mandatory forms from your insurer.
You have 180 days to complete the appeal. An external review can be done at the same time if you are in an emergency situation.
An internal appeal does not guarantee the action will be overturned. If you are still denied, then you can file an external review that gives a neutral third party the ability to come in and make a judgment on the decision. This does not guarantee an overturning of the case either. However if the third party rules in your favor, the insurer is required to provide the services or money from the original request. You have 60 days to file this request.
Some states have a Consumer Assistance Program that provides assistance to you for filing an appeal or to review the decision made by the health insurer. This program is a great starting place if you are unsure of what to do and need assistance.
Other Important Details
For plans beginning as of January 1st, 2012, non-English speakers are allowed the opportunity to obtain appeal information for the language requested. There are only a limited number of languages applicable.
Also, some states and some plans may require multiple levels of an internal appeal before an external review is performed. This means that the internal appeal process would take longer than normal.
Here are a few links that provide useful information:
- Contact information for your state regulator. This is your point of contact with questions regarding internal appeals and external reviews.
- A comprehensive list of information about the appealing process.
- Information about consumer protection in health care law.
Don’t be pushed around by insurance companies. If you believe that you should receive the benefits from your insurer but are denied, file an appeal. If you do not win the appeal, go through the correct avenues and file for an external review. Exercise your rights as a patient!