How to Appeal a Decision on a Health Insurance Claim

All consumers have the opportunity to appeal a health insurance plan decision. Under the Affordable Care Act, effective September 2010, consumers have the right to appeal through their health plan's internal process, which may consist of several levels of appeal. The act also allows an external appeal process, with a non-partial decision-maker. You can appeal a medical determination of care or claim decision made by your health plan. Appeals allow for different reviewers who may have different opinions about the decision.

Instructions

• 1

  Read your explanation of benefits document to assure you understand the claim decision. Call the phone number listed on this document to obtain a full explanation of the claim decision. If your claim was denied for a reason such as benefit exclusion, and the health plan does not cover the services you obtained such as cosmetic surgery, you may not have a strong case for appeal. If you still do not understand the decision, contact your state's insurance regulator for assistance (see Resources).

• 2

  Collect written documentation regarding the decision, including correspondence with your health insurance company, your medical records and notarized statements from your doctor or health care providers as it relates to the claim you wish to appeal. The information you collect must support your appeal and attempt to show why the health plan decision should be re-reviewed.

• 3

  Call your health plan or send them a written request to file a first-level internal appeal. Your provider or a legal representative can file an appeal on your behalf. Follow your health plan's appeal procedures and provide any supporting documentation showing why the decision should be overturned. The health plan will make a determination within a specified time frame, based upon risk, their policies and applicable laws.

• 4

  File a second- and third-level appeal or however many your health plan allows until the appeals are exhausted, should each level uphold the original decision. Initiate an external appeal with an independent impartial reviewer after you have exhausted all internal levels without a decision favorable to you. The directions on how to initiate these appeals are located in the written documentation sent to you with each subsequent decision.

• 5

  Call your employer's Human Resources department benefits representative to advocate on your behalf if coverage is through an employer-sponsored plan. HR may escalate the issue to their insurance broker, if they support your appeal. Some companies retain the final right to override the health insurance company's decision to pay the claim.