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The Appeal Duration for a Denial on a Health Insurance Claim

If you receive a health care authorization or claim denial, you have the right to appeal. All health insurance and health management companies maintain appeal policies. These policies specify turnaround times on reaching an appeal determination. If the circumstance is imminent, such as a current hospital admission, the appeal decision will be expedited. The Affordable Care Act contains provisions for appeal durations. Patients and providers may have several levels of appeal, should the original decision be upheld.

  1. The Affordable Care Act

    • The Affordable Care Act provisions on appeal allow for appeal rights and timely turnaround times for decisions. The federally mandated act specifies that urgent appeal decisions must be provided within 72 hours. Appeals regarding pre-authorization of care must be provided within 30 days. Denials for claims and services previously received must be provided within 60 days. The insurer must provide clear explanation of the appeal decision in a language you can understand. The Affordable Care Act also mandates that, effective July 1, 2011, you will have access to an external appeal review.

    Appeal Timeframes

    • Insurance and health care management companies largely base their appeal timeframes on state and federal laws, accreditation standards and individual customer contracts. In addition to the laws put forth by the Affordable Care Act, many states have laws governing appeal turnaround time. You can find these by calling your state insurance commissioner. Many insurers maintain turnaround times more stringent than those mandated by the Affordable Care Act. For example, Horizon Blue Cross Blue Shield of New Jersey provides a 24 hours turnaround time on urgent appeal determinations, and Aetna provides a decision within 36 hours.

    Appeal Levels

    • The appeal process does not stop after the initial appeal. If your appeal upholds the original decision, you may have the option of a second or third level internal appeal, in addition to an external appeal. Internal appeals are conducted within the insurance company, although different reviewers look at your appeal. If the decision still stands after internal appeals are exhausted, you can request an external appeal. An impartial external reviewer, who does not work for the insurance company, will consider your appeal request and make a binding decision.

    How to Appeal

    • You or your doctor can initiate an appeal. Call your insurer to request a formal appeal. You can also submit an appeal request in writing. Before you initiate an appeal, ensure that you understand the reason for denial. Gather supporting documentation that shows reason for the original determination to be overturned. Submit this information, such as letters from doctors, correspondence with the insurance company and your medical records, with your appeal request.

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