The Affordable Care Act established a bunch of rules and regulations protecting consumers from decisions made by insurance companies. Among these rules, there are clear cut protections against denials of coverage. Additionally, a process has been established when things still go wrong.

You can read more about this process in detail here.

Step One- Ask the insurance company to reconsider. #

This sounds obvious, but the first thing to do is to call the insurance company and just ask them pay.  Now the reason for this is that they are required by law to tell you why your claim was denied and what you can do to dispute their decision.

The time frame that the insurance companies must adhere to in telling you why, in writing, are;

• Within 15 days if you’re seeking prior authorizations for treatment
• Within 30 days for medical services already covered
• Within 72 hours for urgent care cases.

Step Two- Decide how you want to appeal. #

There are two ways to appeal a health plan decision, and internal appeal and an external appeal.

Internal appeal #

If your claim is denied, and internal appeal is when you ask the insurer to review their decision.  Each insurance company has a slightly different process on how they handle appeals, and specifics on where you can find the documents you need and where to send them will be located both in your policy documents and on the denial letter you would have received from the insurance company.

You will need to complete all forms required by your health insurer and submit any and all additional information that you want the company to consider, such as letters from a doctor.  Your state Consumer Assistance Program can help you with all of this.  You will need to have this filed with the insurance company 180 days from receiving notice that you claim was denied.

This process can take time unfortunately.  ACA specifies that the insurance company has 30 days to complete their review if the service has not yet been completed, 60 days if the service has been completed, and 4 business days if you file an expedited appeal under grounds that a standard appeal process would jeopardize your life. 

Make sure that you keep all the paperwork and information related to this claim and denial for reference later down the road if needed.  The paperwork that you will need includes

• The explanation of benefits you received.  This is a letter that the insurance company would have sent you showing what payments where approved and/or denied.  You receive one of these for every procedure, regardless of it is approved or denied.
• A copy of the request for appeals that you sent the insurance company
• All documents you sent supporting your position, such as letters from doctors.
• A copy of the form that you will be required to sign if you had someone else help you file the appeal.
• All notes with dates about any phone conversations you may have had with your insurance company or your doctor that may relate to this appeal.  Make sure to be details and include names, titles, dates, and times in addition to the specifics of the conversion.

**Keep the originals, only submit copies**

The actual appeal itself will need to be the original, so make a copy and keep that for your records.  But everything else, make sure to make a copy of and send the copy only.

External appeal #

This is when you seek out an independent third part and usually comes after an internal appeal failed to convince the insurance company to pay the claim.  When this happens, the insurance company no longer has any say if the pay the claim or not and is required by law to uphold the decision of the external reviewer.

Only certain types of denials can go to external review.  Those include;

• Denials that involve medical judgement where your provider and disagrees with the insurance company.
• A denial where the treatment is experimental.
• Cancellation of coverage based on your insurer’s claim that you gave false information when you applied for coverage.

The review process for external appeals varies depending on where you live.  Insurance companies are required to follow a process that meets the federal consumer protection standards, but depending on which state you live in, your state may go above an beyond these guidelines.  If you state is stricter than the federal standards, then your state board will handle the external review, otherwise the process is handled by the federal Department of Health and Human Services. 

When you look at the Explanation of Benefits given to you on the final denial from your internal appeal, there will be information given on who to contact for an external review.  You can also visit CMS using this link for help filing a request, or call 1-888-866-6205 to request a review over the phone.  Request for review can be faxed to 1-888-866-6190 or emailed to ferp@maximus.com.

You may appoint a representative, such as a doctor, to file the review on your behalf.  Te form needed for that can be found here.

External appeals last no more than 45 days after the request was processed and if they are expedited they take no more than 72 hours.