Health Care Reform required health plans and insurers to implement internal appeal procedures and document those procedures within each client's plan document or contract. If the claim is denied or the member's health insurance coverage cancelled, plan participants have the right to an internal appeal. Plan participants may ask the plan or carrier to conduct a full and fair review of its decision. If the case is urgent, the timeline for completion of the internal appeal is expedited.
There are 3 steps in the internal appeals process:
1. Member files a claim: A claim is a request for coverage. The member or a health care provider will usually file a claim to be reimbursed for the costs of treatment or services.
2. The health plan denies the claim: The insurer must notify the member in writing and explain why:
- Within 15 days if the member is seeking prior authorization for a treatment
- Within 30 days for medical services already received
- Within 72 hours for urgent care cases (As soon as possible, taking into account the medical urgency)
3. The member files an internal appeal: To file an internal appeal, the member needs to:
- Complete all forms required by the health insurer. Or they can write to their insurer with their name, claim number, and health insurance ID number.
- Submit any additional information that the member would want the insurer to consider, such as a letter from the doctor.
- The Consumer Assistance Program in the state can file an appeal for the member
- The member must file an internal appeal within 180 days (6 months) of receiving notice that the claim was denied. If they have an urgent health situation, they can ask for an external review at the same time as their internal appeal.If the insurance company still denies their claim, they can file for an external review.
Plan participants continue to have the right to receive copies of all information regarding their claim as well as the opportunity to review the claim file. They may also have the opportunity to submit additional information as well as provide testimony which may support their appeal.
This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.