Patient Assistance Resource Center Health Insurance Appeal Guide 03/14

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1 Health Insurance Appeal Guide 03/14 Filing a Health Insurance Appeal Use this reference guide to understand the health insurance appeal process, and the steps to take to have a health plan reconsider its coverage decision. What is an appeal? An appeal is a request submitted to an insurance company for reconsideration of a decision by a health plan, usually in response to a denial of coverage. What are the patient s appeal rights? With the passing of the Patient Protection and Affordable Care Act (ACA) on March 23, 2010, new appeal rights were granted to health plan members. The ACA appeal rights apply to non-grandfathered health plans that either: Went into effect after the ACA was passed; OR Were in effect before the ACA was passed that have made changes resulting in reduced benefits, higher costs to members, or both. Plans not expected to comply with the ACA are those that existed prior to March 23, 2010 that have not made changes resulting in reduced benefits or higher costs to members. These plans are known as grandfathered plans. What types of denials can be appealed? Under the ACA, the following health plan denial decisions may be appealed: Denial Reason Medical Necessity Experimental or Investigational Excluded Benefit Out-of-Network Provider Cancelled or Rescinded Coverage Description Treatment or service does not meet accepted standards of medical care, and is not considered essential for diagnosis or treatment Treatment or service does not have established scientific efficacy and do not meet accepted standards of medical care Treatment or services is not offered contractually as a covered benefit under the health plan Treatment or service is provided by a physician or facility that is not contracted with the health plan Insurer revokes or cancels coverage going back to the date of enrollment because the health plan claims that false or incomplete information was provided at the time of application for coverage Disclaimer: This document does not guarantee coverage and is meant to serve as a guide. Should you need assistance or more information on coverage options, please call the CF Foundation s Patient Assistance Resource Center at (888) or send an to

2 What type of health plan does the member have? There are two types of private health plans: 1. Employer-Sponsored Plan A group health plan obtained through an employer or other entity that covers all individuals (their spouses and dependent children) in that group. Types of Employer-Sponsored Plans: Self-Funded and Fully-Insured In a fully-funded group plan, the employer purchases insurance from an insurance company and the insurance company acts as the benefits administrator and processes and pays health care provider claims. In a self-funded group plan, the employer assumes the role of the insurance company and processes and pays health care provider claims. Often self-funded plans contract with an independent organization or third-party administrator to process claims and make claim payments. For selffunded plans, the employer decides to cover or not cover a service. Appeals are made directly to the employer s human resources (HR) department. 2. Individual Plan An individual plan is purchased directly from an insurance company. As with fully-funded group plans, the insurance company acts as the benefits administrator and processes and pays health care provider claims. Who regulates a health plan s appeal process? it is important to identify who regulates the plan to determine the appropriate appeal process. REGULATIONS JURISDICTIONS APPEAL REQUIREMENT S Self Funded Group Plans Regulated by federal law, the Employee Retirement Income Security Act (ERISA) of 1974 and ACA. Under ERISA, selffunded plans are exempt from state laws mandating coverage for specific benefits. However, the ACA requires self-funded plans meet minimum coverage requirements. U.S. Department of Labor Must comply with ACA provisions for a standardized internal appeal process. Under the ACA, self-funded plans must also have a clearly defined external review process. Fully Funded Group Plans Regulated by state law, including state regulations and benefits mandates, but ERISA sets a minimum set of requirements regarding both appeal and claim processes. State Department of Insurance Must comply with ACA provisions for both a standardized internal appeal and external appeal process. Individual Plans Regulated by state law, including state regulations and benefits mandates, but ERISA sets a minimum set of requirements regarding both appeal and claim processes. The level of consumer protection varies by state. State Department of Insurance Must comply with ACA provisions for both a standardized internal appeal and external appeal process. Disclaimer: This document does not guarantee coverage and is meant to serve as a guide. Should you need assistance or more information on coverage options, please call the CF Foundation s Patient Assistance Resource Center at (888) or send an to

3 What is the process for an appeal? An appeal generally consists of four phases: I. Claim Request is Filed A claim is a request made to the health plan by a provider or patient to be reimbursed for cost of a service. II. III. Health Plan Denies the Claim Request. When a health plan denies payment for a service, under the ACA the health plan is required to provide: The reason the claim was denied Information on the right to file an internal appeal Guidance on the right to request an external review Contact information for any state Consumer Assistance Program (if available) If the health plan denies: A pre-service claim or a prior authorization the payer will relay verbally to the medical provider and follow-up with letters to both the patient and provider. A post-service claim, the patient will be notified by a mailed Explanation of Benefits (EOB). The health plan must provide written notification: Within 15 days for prior authorization requests Within 30 days of treatment Within 72 hours for urgent cases File an Internal Appeal An internal appeal is the formal process of requesting that a health plan reconsider, via a full and fair review, a coverage decision to deny payment for a service. Note: ERISA regulations require the filing of a standard appeal within 180 days of receipt of the denial letter. Once an internal appeal is filed, the health plan may: Overturn the initial claim denial. Uphold the initial claim denial. Note: In most cases, a member can request a 2 nd level appeal. For individual and fully-insured plans, the next level is often an external review. For self-funded group plans, the next level might be an additional internal level. IV. File an External Appeal An external appeal is a reconsideration of a health plan s coverage denial decision by an outside, independent organization. The external review is conducted by an impartial expert who is not a direct employee of or related to the health plan. If the case is urgent, it is recommended that one file an external review request at the same time as the internal appeal. In most states, a written request for an external review must be filed within 60 days of the date the health plan sent a decision. The external review may either: Overturn the health plan s decision; OR Uphold the health plan s decision

4 The health plan is required by law to accept the external reviewer s decision. What possible documents are needed to file an internal appeal? Copy of insurance card Copy of the denial letter or EOB Treatment history, including an explanation of services provided by the provider s office Peer-reviewed journal article to support the opinion that the denial should be overturned A letter or Authorized Representative Form signed by the patient. Note: Needed if someone (doctor or anyone else) is going to file an appeal on the patient s behalf. An appeal letter or health plan appeal form (if available) How are internal appeals filed? 1. Read the denial letter or EOB to learn: The specific reason for the denial The provision supporting the health plan s decision What documentation/supporting data is required for an internal review? What is the plan s appeals process and associated timeline? What the options are for the appeal submission? 2. Learn the health plan details: Read policy, contract or Summary Plan Description Speak with HR (self-funded plan) group plan Visit the health plan s website or contact customer service to collect information on the type of plan, what services are covered, how the plan is funded and the internal review process. 3. Review the health plan s benefits booklet to understand what the health plan does not cover (excluded benefits) for contractual denials. Many plans list this information in the exclusions and limitations section. Some plans do not publish this information. For these plans, contact customer service to obtain this information. 4. Review the health plan s medical policy for the service to understand the clinical rationale used for denials based on medical judgment. 5. Keep a record of all correspondence and conversations with the insurance company: health plan representative name(s), date(s), time(s), topics of discussion and any action steps. 6. Write the appeal letter and include: Member name Policy and group number Claim number (if available) Medical history and treatment information The specific reason the health plan denied the claim The rationale health plan coverage of the claim 7. Obtain information or letter from provider detailing why the service is medically necessary. Note: This may include copies of medical records. 8. Gather medical evidence, such as published article, clinical guidelines, to support health plan coverage of the claim. Note: Search a website run by the National Institute of Health.

5 9. Understand the time limits the health plan has in place for all appeal stages and file the appeal within the time limit. Note: Failure to observe time limits may result in the loss of the opportunity for an internal and external review. 10. Mail the appeal letter via certified mail. Note: Certified mail allows for tracking and confirmation of delivery. 11. Call the health plan to obtain the status of the appeal. Note: Continue to follow up until an official mailed response has been received. How long does an internal appeal take to complete? The health plan must make a decision: Within 30 days for a prior authorization request; Within 60 days for medical services already completed; OR Within 72 hours for urgent cases. When should an external review be requested? An external review should be requested when the health plan denies based on a determination that the service is deemed not medically necessary, experimental or investigational Based on the cancellation of coverage due to the health plan s claim that false or incomplete information was provided during the application for coverage How are external appeals filed? 1. Review the denial notice for instructions on how to request an external appeal. Note: Some health plans provide an external appeal form with the denial notice when services are deemed not medically necessary, experimental or investigational, a clinical trial, a rare disease treatment, or outof-network. Visit the state s Department of Insurance website to download external review form(s). 2. Submit a written request for an external review within 60 days of receipt of the health plan s internal review decision. Note: Some plans may allow more than 60 days to file the request. 3. Include all documentation required for the external review, which may include: A copy of the insurance card A completed external review form A copy of the letter from the health plan stating that the appeal decision is final An appeal letter that includes: Member name Address and phone number Date of birth Health plan information (company name, plan type, phone numbers) Policy number Claim number (if available) Date(s) of service Explanation of the benefit decision being disputed Proposed resolution Copies of supporting documentation

6 A completed Medical Records Release Form An Appointment of Authorized Representative form. Note: Needed only if appeal is being filed by someone other than the patient. Submit the written request for an external appeal via certified mail. How long does it take to complete an external review? External reviews are typically decided no later than 60 days after the request is received. What happens if the independent review organization upholds the health plan s decision? If the health plan is governed by ERISA, the policyholder may file a law suit under section 502(a) of ERISA. Need help navigating the appeal process? The PARC provides Case Management and Technical Assistance services to help people with CF and CF care providers with a wide range of insurance coverage and reimbursement issues. People with CF, their families and care centers may contact the PARC at Monday through Friday from 8:30 a.m. until 5:30 p.m. ET or by at

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