Arthritis Foundation Legislative Position Statements

Arthritis Foundation Position Statement on Health Benefit Claim Denial and Appeals Process Disclosures

Issue

It is not unusual for an insurer to deny coverage for a medication or a treatment. Common reasons for denials may include the following: the procedure is not covered under the plan, the provider is out of network, the procedure is considered cosmetic, requires following a step therapy protocol or simply that not enough information was provided by the physician.

When an adverse benefit determination or denial is made, it is imperative that the insured know the specific reason for the denial so that they may consult with their physician to evaluate the appropriateness of the decision. The insurer should also provide the insured with information regarding the process, time frame and contact information for appealing the decision.

Background

Many health insurance plans will deny coverage for a medication or treatment and not advise the insured of the reason for the denial or how an appeal could be made. A person who doesn’t know that they have the right to appeal or the information necessary to conduct the appeal may be wrongfully or inappropriately denied access to medications and treatments that are critical to their health.

Providing greater disclosure and transparency will help to ensure that coverage determinations are accurate and permit access to benefits to which an insured is entitled to receive.

Arthritis Foundation Position

The Arthritis Foundation supports legislation that provides clear disclosure of the process for appealing insurance coverage denials and provides the following:

  • Requirement that notices of an adverse benefit determination or denial be made to the insured in writing within three days of the decision.
  • Notice of the specific reasons for the action taken.
  • Notice of the insured’s right to appeal the action taken.
  • Notice of the U.S. Postal Service address, internet web page address or telephone number, as appropriate, to make an appeal.
  • Notice of the conditions or methods by which an appeal must be made.
  • Notice of the time period in which an appeal must be made.

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