Define the Claims Appeal in Health Insurance

When health insurance companies refuse payment of a medical bill, the provider of health services has the right to file an appeal to request reconsideration. Patients also have the right to appeal as responsibility for payment falls on them for any services left uncovered by their insurers.

Definition

• MedPlan Access defines a health insurance claim as a document presented to a doctor or other health care provider, seeking payment for services. The definition of the word "appeal" relates to asking for reconsideration when a denial of payment occurs.

Types

• Per Flexible Spending Accounts for Federal Employees (FSA FEDS) appeal filings cover non-payment or reduced payment of services, products or treatments deemed ineligible for coverage or an appeal can serve as a request to change eligibility status for certain services.

The Appeal Process

• Appealing a claim denial, under FSA FEDS guidelines, can involve multiple steps beginning with an initial appeal submitted by phone, fax, email or postal mail. If you are unhappy with the result, the next step is a first level written appeal to include copies of pertinent documents (doctor's letter, explanation of benefits, and so on). Submissions must be mailed or faxed. If necessary, you may utilize a second level written appeal, or as a last resort, you can request a third party independent review.

Considerations

• CIGNA, a top provider of health insurance, allows appeals filing for claims denied for timely filing, duplicate or incomplete submission, lack of prior authorization for services rendered or medical necessity.

Rights

• According to the Washington State Patient's Bill of Rights, health insurers "must have a grievance process in place" to allow patients to appeal claim denials. The patient guidelines also state that insurers must respond to appeals in a fair and timely manner, giving instruction as to how you, the patient, can make use of the full appeal process until your grievance is resolved.