Appeals Process – Commercial, Employer and Marketplace Plans

Under the Affordable Healthcare Act (ACA), if you disagree with your insurance plan’s refusal to preauthorize or pay their portion of the cost for a procedure, device, medication or test, you have the right to appeal the decision. However, this right only applies to plans created after March 23, 2010 and older plans that have been updated in certain ways. These health plans cannot drop your coverage or raise your rates because you ask that the denial be reconsidered. If the plan is considered a grandfather plan, you are not guaranteed the right to appeal a denial. If you are not sure which type of plan you have, check with your insurer.

Before you decide to file an appeal, review the covered benefits, exclusions and limitations in your plan’s benefits booklet. If the service or product is clearly listed as not covered or excluded, and the limitation is clearly identified, it’s unlikely that your appeal will be successful.

If you want help filing an appeal, you can appoint a representative. Your representative can be a family member, friend, advocate, attorney or doctor. If you are appointing a representative, the first communication must include a statement authorizing the release of your personal and identifiable health information to your representative.

If English is not your native language, you may be entitled to request information about appeals in the language you speak (Spanish and some other languages are available). This right applies to plans that started on or after January 1, 2012.

When you receive your explanation of benefits (EOB) stating that your claim has been denied, you’ll also receive information from the insurer with clear instructions about the appeal process and the deadlines for appeal. Read this information carefully and follow all the steps exactly as outlined. Make sure your appeal specifically addresses the denial issue. For example, a denial due to a coding error shouldn’t be appealed based on medical necessity. Also, it’s very important that your appeals are submitted within the time frame allowed by your plan.

Appeals are less likely to be successful if they are:

  • Incomplete or include incorrect information
  • Have a highly emotional tone reflecting feelings of frustration, pain, or anger rather than facts
  • Include unnecessary details

Appealing a claim can be challenging, so you may consider getting help from an experienced claims assistance organization. Your state may have a Consumer Assistance Program that can help you file an appeal or request a review of your health insurance company’s decision if you are not sure what steps to take. If you have some basic questions about the appeal process, you can call the Arthritis Foundation helpline at 1-844-571-HELP (4357). There are some pharmaceutical companies who offer benefit verification and appeals assistance for drug-related appeals so check with your drug manufacturer.

There may be situations that don’t qualify for the appeal processes outlined below. For example, if you think the plan is discriminating against you because of your race, ethnicity, gender, religion or sexual orientation) and the health insurer receives any federal funds (such as premium tax credits, Medicaid, or Medicare), you can file a complaint with the office of civil rights in the Department of Health and Human Services.

Self-Funded Plan Appeals

With a self-funded plan, the employer is the insurer and is responsible paying the medical bills. The employer may contract with a health insurer to act as a claim administrator. The employer determines the appeal process.

The human resources department will be your source for information about coverage and the appeal process. If the plan was introduced after March 23, 2010, your health insurer must provide an external review process that complies with federal (ACA) rules.

The last step in the process for self-funded plans is an appeal to the federal Department of Labor. There is no option to file an appeal with the State Department of Insurance.

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