An appeal is your request to your health plan asking them to review their decision not to pay their part for some piece of your health care.
Your health plan has to follow guidelines about its appeals process. It must:
- Communicate the appeals process to everyone enrolled. When you need it, you can call your plan's customer service department or check their web site.
- Respond to your appeal within 45 days. If the issue is medically urgent, they must respond within 72 hours.
- Put your appeal through an internal review, meaning people who work for the health plan look at your request.
- Allow you to ask for an external appeal if your plan still won't cover the service after its internal review. An external review means an independent organization looks at your request. This was added in 2010 as part of the Affordable Care Act. If your external appeal is denied, then you have to pay for the service.
Health plans that existed before March 23, 2010, are grandfathered plans. These older plans have not had to follow the most current appeals process. Starting Jan. 1, 2014, though, all private health plans will have to follow the same appeals process.