Arthritis Foundation Legislative Position Statements

Arthritis Foundation Position Statement on Health Benefit Claim Denial and Appeal 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, the plan requires a step therapy protocol, or simply that not enough information was provided by the physician.

When adverse benefit determinations, or denials, are made, it is imperative that plan members know the specific reason for denials so they can consult their physician to evaluate the appropriateness of the decisions. The insurer should also provide 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 patient of the reason for denial or how an appeal can be made. A person who doesn't know 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 ensure that coverage determinations are accurate and permit access to benefits a member 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 plan member in writing within three days of the decision.
  • Notice of the specific reasons for action taken.
  • Notice of the patient’s right to appeal the action taken.
  • Notice of the U.S. Postal Service address, webpage 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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