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You Have Rights! Health Insurance Edition

May 29, 2023 | Healthcare

Although health insurance providers seem like judge, jury, and executioner when you are denied coverage or a claim is denied, that is not necessarily the end of the story.  You do have rights, probably more than you realize.

Let’s start with the Health Insurance Marketplace.  You can appeal if you think you are eligible and are denied coverage or there are issues with the cost of coverage or the date coverage started.  With some exceptions, the appeal must be made within 90 days of the receipt of your Eligibility Notice.  Oddly, you cannot appeal the date coverage ended or change the information on your application for coverage.  The quickest way to appeal is online at: https://www.healthcare.gov/marketplace-appeals/ways-to-appeal/.  From that link you can easily upload any documents required to substantiate your appeal.  Other alternatives are fax (877-369-0130) or a mailed appeal to:

Health Insurance Marketplace
ATTN: Appeals
465 Industrial Boulevard
London, KY 40750-0061

If your health insurance company denies a claim , your insurer must notify you in writing and explain why within the following timeframes

  • 15 days for preauthorizations;
  • 30 days for denials of claims submitted; and
  • 72 hours for urgent care cases.

Insurance companies are required to let you know you can dispute that decision and there are two possibilities: internal appeal or external review.

INTERNAL APPEAL

Once denied you must file an internal appeal within 180 days of receiving the notice of denial.  You must complete any forms required by the company and submit any additional information that should be considered.  For preauthorizations, often your physician will assist.  You have the right to see your file, usually at no cost, to find information to support your appeal.  Yes, hidden in what feels like an endless, unreadable avalanche of words that seem to accompany any health insurance correspondence is the notice that you have the right to access your file, and you should do that before filing any appeal.  ProPublica has started a project to collect these files and has already published shocking details of attempts to limit costs and drive profits at the expense of policyholders.

Most companies do not provide a form or template to request your file.  The following link (https://static.propublica.org/projects/pdfs/ClaimFileRequestTemplate.pdf) will take you to a template developed by ProPubulica, adapted from one published by Health Law Advocates, that should be accepted by all insurance companies.  Copies of any relevant additional information should be sent with the completed form.

If it is not clear from your denial notice where the appeal form should be sent, you can contact the company’s appeals department or HIPPAA unit.  ALL contacts, whether in writing or by telephone, need to be documented for your protection.

An insurance company should process an internal appeal within:

  • 30 days for a preauthorization; or
  • 60 days for a submitted claim.

You should receive a written decision from the insurance company responding to the appeal, and if that decision is a denial you can go to the next step and request an external review.  By law, the insurance company must accept the results of the external review as the final decision on the claim.

EXTERNAL REVIEW

You can request an external review within 4 months of the date you receive a notice or final determination of denial from your insurer.  These types of denials may be reviewed:

  • A denial based on medical judgment;
  • A denial claiming the treatment is experimental or investigative; and
  • Cancellation of coverage based on a claim that the application for coverage contained false or incomplete information.

The process depends on the state you live in but in all states the review is completed within 45 days or within 72 hours for a medical emergency.  In exigent circumstances, this review can be conducted even before the results of an internal appeal are known. The insurance company’s final denial of internal appeal will state the organization to contact to initiate the review.  If the insurance company participates in the HHS-Administered Federal External Review Process, you can find information and file a request for review using this link: https://externalappeal.cms.gov/ferpportal/#/home.

While it does feel like we policyholders are in a lopsided battle with our insurance companies, we do have ammunition to help level the playing field, and we need to use all the tools at our disposal when it comes to preserving our health.

Article submitted by Lois S. Fried, CPA, CFE, CVA, ABV

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