An appeal is your request to your health plan asking it to review a decision, usually a refusal, to pay for part of your health care.
Your health plan has to follow guidelines about its appeals process. It must:
- Communicate the appeals process to everyone enrolled. Information about how to appeal should be included in your letter denying payment. You can also call the plan's customer service department or check their web site.
- Complete your appeal within 30 days if you're seeking prior approval for a treatment. The company must complete an appeal within 60 days for treatment already received.
- Put your appeal through an internal review, meaning people who work for the health plan evaluate 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.
You must file your internal appeal within 6 months of receiving notice that your claim was denied. If you have an urgent health situation, you can ask for an external review at the same time as an internal appeal.