Note: The following text is part of HFA’s Patient Insurance Log Book, which is provided free of charge to all participants in HFA’s Project CALLS.
Your insurance company may deny a payment for a claim, terminate coverage, or deny eligibility for certain things. If this happens, you, as the consumer, are entitled to appeal your health insurance company’s decision. You need to file an internal appeal within 180 days (six months) of receiving notice that payment for a claim was denied, coverage was terminated, or the consumer was determined ineligible for certain things.聽If there is an urgent health situation, you can ask for an immediate external review.
You have the right to appeal the denial of a payment for a claim or termination of coverage. You have the right to appeal a denial of eligibility for the following items:
- Eligibility to purchase a Marketplace plan;
- Eligibility to purchase a plan outside of the regular open enrollment period;
- Eligibility for premium subsidies and cost savings;
- The amount of cost savings for which you are eligible;
- Medicaid or CHIP eligibility; and
- Eligibility for an exemption from the individual mandate to enroll in health insurance
FIRST: You can appeal your insurance company first through an internal appeal. Through this process, the insurance company does a full and fair review of its decision.1
To submit an internal appeal, you need to:
- Complete all the forms required by your health insurer. These forms may be found online or you may be able to complete them online. . There may be no forms to complete and your insurer may require a聽written submission of the issue; and
- Submit any additional information that you want the health insurer to consider, such as a letter from your doctor.
Make sure you keep copies of all your information related to your claim and the denial.
SECOND: If your insurance company denies your internal appeal, you may be able to have an independent third party review your appeal and decide to uphold or overturn your insurance company’s decision. This process is referred to as an external review. Standard external reviews are decided as soon as possible and should take no longer than 60 days after the request was received.2
If the denial falls into the following categories, it may qualify for an external review:
- Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan.
- Any denial that that involves a determination that a treatment is experimental or investigational.
- Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information聽when you applied for coverage.
If you believe you qualify to have an external review, before submitting you must check your insurance plan to see how your insurance company participates in an external review process because it could be different. Your state may have an external review process; however, if it does not meet the standards of the Federal Department of Health and Human Services (HHS), HHS will handle your external review.
Look at the information on your Explanation of Benefits (EOB) or on the final denial of the internal appeal by your health plan. It will give you the contact information for the organization that will handle your external review.
Depending on your plan and where you live, the following may apply to you:
- Insurance companies may choose to participate in an HHS-administered process or contract with independent review organizations in states where the federal government oversees the process.
- If you’re in an employer-sponsored health plan, you may not be eligible to participate in a state-run external review process.
- If your plan doesn’t participate in a state or HHS-administered external review process, your health plan must contract with an independent review organization.3
To submit an external appeal, you must:
- File a written request with whichever entity you have determined will handle your appeal (see above) within 60 days from the day your insurer sent a final decision.
- Once the external reviewer issues their final decision, you and your health insurance company are required by law to accept the external reviewer’s decision.
HFA is aware that United Healthcare has instituted a restricted formulary for bleeding disorders products. If you have United Healthcare and your product of choice is not covered, please click here聽for information specific to United Healthcare on appeals and exceptions processes for formularies.
1G Internal Appeals, Healthcare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/ internal-appeals/ (visited Aug. 5, 2015).
234External Review, Healthcare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (visited Aug. 5, 2015).