The Pennsylvania Insurance Department s. Your Guide to filing HEALTH INSURANCE APPEALS

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1 Your Guide to filing HEALTH INSURANCE APPEALS Sometimes a health plan will make a decision that you disagree with. The plan may deny your application for coverage, determine that the healthcare services you requested are not covered or only partially covered or cancel your policy back to the date it started. If you disagree with the health plan s decision, the first thing to do is contact your health plan and your health provider to see if you can resolve the situation. If you continue to disagree, you may have the right to file an appeal. The Affordable Care Act (ACA), the federal healthcare reform law passed in March 2010, provides consumers with several appeal rights. These rights apply to nongrandfathered, fully-insured plans and self-funded plans. Health plans must tell you if your plan is grandfathered. These plans generally do not have to follow ACA appeal guidelines with some exceptions. Contact the health plan for this information. This guide provides information on how consumers can file a health insurance appeal if they are covered by a non-grandfathered plan. Learn more at PAHealthOptions.com Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 1 of 13

2 What is an appeal? An appeal is when you ask a health plan to reconsider its decision to deny payment for a service or treatment. There are generally three types of appeals: 1. INTERNAL APPEAL: The health plan reviews the situation internally. You can file an internal appeal for just about anything. Your plan may offer several levels of internal appeal. If the health plan: DENIES A PRIOR AUTHORIZATION for services (a request made by you or your healthcare provider to the health plan to approve a specific treatment or service before it is delivered commonly called a Pre-Cert, short for pre-certification), it will make a verbal denial to the medical provider and follow-up with a letter to you and the provider. DENIES A POST-SERVICE CLAIM (a claim submitted by you or your health provider after receiving treatment or service) in whole or in part, you will be informed of the denial on your Explanation of Benefits (commonly called an EOB). You must exhaust all of the internal appeals available to you before moving to an external review. 2. EXTERNAL REVIEW: An independent third-party expert reviews the situation. External reviews are available only for rescission of coverage and coverage decisions involving issues of: healthcare setting level of care effectiveness of a covered benefit experimental/investigative treatment effectiveness of a covered benefit experimental/investigative treatment other matters involving medical judgment (also called Adverse Benefit Determinations) healthcare setting, level of care External reviews are generally not available for contractual issues such as excluded benefits, limitations and other contract conditions. 3. EXPEDITED REVIEW: In an urgent care situation, the internal appeal and external review can be handled together if the case is subject to external review Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 2 of 13

3 What if my application for health insurance is rejected? Appeals regarding rejections of health insurance applications are not covered under ACA. However, you can take steps to better understand or refute the health plan s decision or reapply for coverage. When you apply for health insurance, the plan uses a process called medical underwriting to determine whether or not to offer you coverage and how much to charge you for coverage. Medical underwriting includes a thorough review of your medical history. If your application is rejected: Carefully review the rejection letter. Contact your physician to see if they can provide any documentation on your behalf. Follow the appeal process, if any, outlined in the rejection letter. If you choose to correspond with the health plan regarding denial of the application, a sample letter is included at the end of this guide. Keep copies of all correspondence in a safe place. Learn more at PAHealthOptions.com Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 3 of 13

4 The internal appeal process 1. You or your healthcare provider request a pre-authorization or file a claim to be reimbursed for the cost of treatment or service. 2. If the plan denies the pre-authorization or claim in whole or in part, or rescinds coverage back to the issue date of the policy, it must notify you in writing of the denial and explain why the claimwas denied. It must do this within: 15 days for prior authorization 30 days for medical services already received 72 hours for urgent care cases The denial notice must explain: The reason for the denial Your right to appeal the health plan s decision How to file an internal appeal Your right to file an external review, if necessary The contact information for the Pennsylvania Insurance Department, Bureau of Consumer Services Availability of linguistic services within certain communities If you live in a county where at least 10 percent of the population speaks the same non-english language, the appeals notice must tell you how you can get the notices translated and what customer help is available in that language. 3. If you receive a denial notice, check your member handbook to be sure you understand your coverage. Contact your health plan and healthcare provider to see if you can resolve the claim without going through the appeals process. If you are not satisfied, you may begin the formal appeals process. 4. You may file an internal appeal, in which you ask the plan to review its decision to deny your claim or rescind your policy. You must submit your written request for internal appeal to your company at the address it provides. Submit any additional information, such as a letter from your healthcare provider, which the plan should consider. You must file your appeal in writing within 180 days of receiving notice that your claim was denied. 5. The plan makes its decision either to stand by its original decision to deny the claim or to provide benefits for the claim. The plan must make its decision within: 30 days for prior authorization or rescission 60 days for medical services already received 72 hours (or less) in urgent care cases 6. The plan may have a second level of internal appeal that you will need to follow before the internal process is complete Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 4 of 13

5 HOW TO REQUEST AN EXTERNAL REVIEW You may request an external review if the health plan upholds its internal decision and that decision involves an Adverse Benefit Determination (ABD) as defined by the ACA. The external review will be conducted by an independent expert who does not work for or who is not related to the health plan. If the external reviewer overturns your plan s denial decision, the plan must make the payments or services you requested. The health plan will advise you of the levels of appeals available to you. Generally, all issues can be appealed internally but only ABDs are eligible for external review. In Pennsylvania, plans may choose to handle external reviews in one of two ways: The health plan has either contracted with an independent third-party review organization (IRO) or has opted to have an entity under contract with the federal government conduct the external review. Health plans had to report by January 2012 which external review process they were going to use. Your plan is required to advise you of next steps within the final internal appeal determination. The internal appeal decision will tell you how long you have to file for an external review. Under some plans, it may be as little as 60 days. HOW TO FILE FOR EXPEDITED REVIEW If you have an urgent healthcare situation, you may ask your health plan to expedite the appeal process. In an urgent care situation, the internal appeal and external review may be handled together (if the case is an ABD subject to external review). You are able to file an expedited appeal in one of these two situations: You are currently receiving, or were prescribed to receive, treatment and have an urgent situation. An urgent situation is when a medical provider believes a delay in treatment could jeopardize your life or health, affect your ability to regain maximum function or subject you to intolerable pain. You have an issue related to admission, availability of care, continued stay or emergency services and have not been discharged. You or your authorized representative may verbally request an expedited appeal from the health plan. The health plan must respond as soon as possible but no longer than 72 hours after your request. It may respond verbally, but must follow-up with a written decision. WHAT ARE MY RIGHTS IF I WANT TO APPEAL A HEALTH PLAN DECISION? You have the right to know why a claim has been denied. You have the right to see what the health plan relied on in making its denial decision. You have the right to appeal the plan s decision and have the company review its decision. If the health plan upholds its original decision during the internal appeal process, you have the right to an independent third party review in cases of Adverse Benefit Determinations (including rescission). Both you and the plan have to abide by the third party s decision. It is your right to ask for an appeal. Your plan cannot drop your coverage or raise your rates because you ask them to reconsider a denial Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 5 of 13

6 Need help? If you need help filing an internal appeal or an external review request, please contact the Pennsylvania Insurance Department. PENNSYLVANIA INSURANCE DEPARTMENT Bureau of Consumer Services 1209 Strawberry Square Harrisburg, PA PAHealthOptions.com Pennsylvania participates in the federal external review process. This means that your health insurance company uses either a process administered by the federal Department of Health and Human Services (HHS) or an independent process. If it uses the HHS process, you may call to request an external review request form. Once you have completed the external review request form, you may submit your request in one of three ways: THINGS TO REMEMBER Complete all forms accurately and honestly. Keep copies of all paperwork or correspondence pertaining to a claim. Write down the names and contact information for everyone you speak to or regarding the claim. Keep a timeline of events, starting with the date of service or when the claim was initially denied. Include details about all conversations or s you have about your claim. Pay close attention to required timeframes to be sure both you and the health plan are responding according to the timeframes given in the law. Fax: Mail: P.O. Box 791, Washington, D.C Alternatively, you may be able to file your request online at If your health plan does not participate in the HHS external review process, or if your health plan is self-insured, contact your health plan for information on how to file for an external review Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 6 of 13

7 GLOSSARY INDEPENDENT REVIEW ORGANIZATION (IRO) An independent third-party organization contracted to conduct an external review of health appeals. INTERNAL APPEAL A review of a health plan s determination that a requested or provided healthcare service or treatment is not or was not medically necessary. All plans are required to conduct an internal review upon the request of the patient or the patient s representative. -A- ADVERSE BENEFIT DETERMINATION (ABD) A plan s decision to deny a claim in whole or in part based on medical judgment or rescission. AFFORDABLE CARE ACT (ACA) (also known as the Patient Protection and Affordable Care Act) is the federal healthcare reform legislation signed by President Obama in March C- CPT CODE Current Procedural Terminology (CPT) codes are numbers assigned to a medical, surgical or diagnostic service, from a healthcare provider. -E- EXPLANATION OF BENEFITS (EOB) A document sent by your insurance company that gives you information about how an insurance claim from a healthcare provider was paid on your behalf. EXTERNAL REVIEW An outside review by an independent third party of a health plan s Adverse Benefit Determination. -G- GRANDFATHERED PLAN A health plan in which an individual was enrolled prior to March 23, 2010, and that has not significantly changed its benefits or cost-sharing requirements. Grandfathered plans are exempted from most changes required by ACA. New employees and family members may be added to group plans that are grandfathered. -I- -M- MEDICAL JUDGMENT A healthcare provider s judgment, based on observation, knowledge and experience, leading to a diagnosis or treatment decision for a patient. MEDICALLY NECESSARY Generally speaking, services or supplies needed for diagnosis or treatment that meets accepted standards of medical practice. Your health plan may have a more specific definition. MEDICAL UNDERWRITING The process a health plan uses to determine your health risk when you are applying for health insurance. Companies use this to decide whether or not to offer you coverage, how much to charge you for coverage and if there will be exclusions or limits Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 7 of 13

8 -R- -U- NETWORK ADEQUACY For plans that use networks, the term for evaluating whether a plan has an adequate number of healthcare providers in its provider network to allow members to access covered healthcare services without unnecessary barriers. URGENT CARE CLAIM A claim you may make for expedited review of your denied claim. You may make this claim if a medical provider believes a delay in treatment could jeopardize your life or health, affect your ability to regain maximum function or subject you to intolerable pain. PRE-EXISTING CONDITION A physical or mental condition including a disability for which a patient receives diagnosis or care. -N- NON-GRANDFATHERED PLANS Health plans that started after the ACA was signed into law or plans that existed before the law was signed that have made significant changes that have reduced benefits and/or raised costs. -P- RESCISSION The retroactive cancellation of a health insurance policy. Rescission is prohibited except in cases of fraud or intentional misrepresentation of a relevant fact Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 8 of 13

9 Sample letter to request an internal appeal Your Name Your Address Date Address of the Health Plan s Appeal Department Re: Name of Insured Plan ID#: Claim #: To Whom It May Concern: I am writing to request a review of your denial of the claim for treatment or services provided by name of provider on date provided. The reason for denial was listed as (reason listed for denial), but I have reviewed my policy and believe treatment or service should be covered. Here is where you may provide more detailed information about the situation. Write short, factual statements. Do not include emotional wording. If you are including documents, include a list of what you are sending here. If you need additional information, I can be reached at telephone number and/or address. I look forward to receiving your response as soon as possible. Sincerely, Signature Typed Name Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 9 of 13

10 Sample letter to request an internal appeal (rescission) Your Name Your Address Date Address of the Health Plan s Appeal Department Re: Name of Insured Plan ID#: Claim #: To Whom It May Concern: I am writing to request a review of your rescission of my policy with the effective date of effective date. The reason for rescission was listed as (reason listed for rescission), but I have reviewed my initial application and believe the information provided was accurate. Here is where you may provide more detailed information about the situation. Write short, factual statements. Do not include emotional wording. If you are including documents, include a list of what you are sending here. If you need additional information, I can be reached at telephone number and/or address. I look forward to receiving your response as soon as possible. Sincerely, Signature Typed Name Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 10 of 13

11 Sample letter to request an external review (adverse benefit determination) Your Name Your Address Date Address of the Health Plan s Appeal Department Re: Name of Insured Plan ID#: Claim #: To Whom It May Concern: I am writing to request an external review by an independent review organization (IRO) of the final internal adverse benefit determination I received on date. I have included a copy of that determination with this request. I filed my request for an internal appeal on date in response to the denial of coverage for treatment or service provided by name of provider on date provided. The medical review upheld the original decision. Here is where you may provide more detailed information about the situation. Write short, factual statements. Do not include emotional wording. If you are including documents, include a list of what you are sending here If you need additional information, I can be reached at telephone number and/or address. I look forward to receiving your response as soon as possible. Sincerely, Signature Typed Name Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 11 of 13

12 Sample letter to request an external review (rescission) Your Name Your Address Date Address the Health Plan Provides You for External Appeal Re: Name of Insured Plan ID#: Claim #: To Whom It May Concern: I am writing to request an external review by an independent review organization (IRO) of the rescission determination I received on date. I have included a copy of that determination with this request. I filed my request for an internal appeal on date in response to the original rescission determination. The medical review upheld the original decision. Here is where you may provide more detailed information about the situation. Write short, factual statements. Do not include emotional wording. If you are including documents, include a list of what you are sending here If you need additional information, I can be reached at telephone number and/or address. I look forward to receiving your response as soon as possible. Sincerely, Signature Typed Name Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 12 of 13

13 Sample letter to request review of application denial Your Name Your Address Date Address of Health Plan To Whom It May Concern: I am writing to request a review of the denial of my application for health insurance. I submitted the attached application on date and received the attached denial on date. The reason stated for denial was reason stated for denial. I disagree with this reason because: Here is where you may provide more detailed information about the situation. If you have supporting documents from a physician, reference them here. Write short, factual statements. Do not include emotional wording. If you are including documents, include a list of what you are sending here. If you need additional information, I can be reached at telephone number and/or address. I look forward to receiving your response as soon as possible. Sincerely, Signature Typed Name Strawberry Square, Harrisburg, PA Your Guide to Filing Health Insurance Appeals 13 of 13

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