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> Guide to the Health Insurance Appeals Process
Guide to the Health Insurance Appeals Process
What is an appeal? An appeal is a request to have the insurance company take a new look at a denied claim or a denial of a request for future benefits (such as upcoming surgery). If you have been denied insurance benefits for something which you think is covered by your policy, first contact your insurance company (your customer service telephone number is listed on the back of your insurance card). It's possible that an error was made, which can be cleared up. If the issue is not resolved by contacting the insurance company, and you continue to believe the claim should be covered, you can appeal the decision. Steps in the Appeal Process If the denial is for a medical reason, your health care provider can contact the insurance company and request reconsideration. Your provider may call this a “Provider Appeal,” a “Reconsideration” or a “Peer to Peer Review.” If this step is not taken by your health care provider, or if it is not successful, you have two levels of appeal and possibly a third level (called the Independent External Review). What do I need when filing an appeal?
Most health care providers will help you with your first level appeal. First Level Appeal Most companies request that you file your appeal within 180 days of the denial unless you have good reason for the delay. If the insurance company says your appeal is too late, contact the Bureau of Insurance. The insurance company has 20 business days from the date it receives your appeal to send you a decision letter. If you do not receive this letter within the time frame, contact the insurance company or the Bureau of Insurance. Many companies require your appeal to be filed in writing. If you do not agree with the insurance company’s decision, you can ask for a second level appeal. Second Level Appeal The second level appeal involves insurance company staff who were not involved in the first level appeal. You can ask for a hearing as part of this appeal. You may appear in person or participate by telephone. At the hearing you can present any information you have which might help your case. The information does not have to be different from that used in the first level appeal. If there is a hearing, the insurance company has 50 days to issue their decision. If there is no hearing, the company has 30 days to notify you. If your second level appeal is denied, you may qualify for an external review. External Review An external review is administered by the Bureau of Insurance. The Bureau assigns your case to an independent reviewer (not associated with the insurance company). The independent reviewer hires a health care provider who is an expert on the medical issue being decided. You have the right to a conference call with the reviewing expert, and you may have your own health care provider take part in the conference call as well. The external review process usually takes 30 days to complete. Filing a complaint: You may file a complaint with the Bureau of Insurance at any time. The Bureau’s complaint investigation and the insurance company’s appeals process are different. The Bureau of Insurance is not directly involved in the company’s First or Second Level appeals, but the Bureau does monitor the process to be sure the insurance company is providing the appropriate appeal process. A consumer complaint is investigated directly by the Bureau of Insurance. A complaint investigation and an appeal can take place at the same time. Visit the Bureau’s Web site to file a complaint electronically. You can also call the Bureau to request a complaint form by mail. What if my issue involves medical care or equipment that I need right away? Expedited Appeals If your health care provider believes that you need the medical care in question sooner than it takes to go through the regular appeals process, you can ask for an “expedited” appeal. To qualify for an expedited appeal, your life, health or ability to function must be in serious danger. The expedited first level appeal will take 72 hours or less to complete. If the expedited appeal decision is not satisfactory, you can immediately request an expedited external review by contacting the Bureau of Insurance. The expedited external review will be completed in 72 hours if there is no conference call. Contact us: The Bureau of Insurance is located at:
We welcome you to call or visit us if you need help with any insurance matter. The office is open from 8:00 to 5:00 Monday through Friday. Maine Bureau of Insurance In-state: 1-800-300-5000
Last Updated: March 27, 2012 |
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