The Affordable Care Act (ACA or Obamacare) mandates that consumers have the right to appeal if an insurance company refuses to pay a claim or ends coverage. Insurers must disclose to consumers the reason that their claim was denied or that coverage ended. Insurance companies must also provide instructions for the appeals process.
These appeal rights apply only to health plans or policies that were created or purchased after March 23, 2010. Plans created on or before this date may be considered “grandfathered health plans.” Appeals and review rights may not apply to these plans.
Some states have healthcare Consumer Assistance Programs. These organizations assist consumers in filing an internal appeal and requesting external reviews. If your state does not have a Consumer Assistance Program, there may be other state agencies that can provide guidance. Check with your state’s Insurance Commissioner or Department of Insurance for available resources. Non-English speakers may be entitled to receive appeals information in their native language upon request if their healthcare plan began on or after January 1, 2012.
Many healthcare plans provided through employers are self-insured, meaning that the employer is financially liable for covered medical expenses of employees. Insurance plan documents, including employer self-insured plans, must prominently state who is responsible for administrating benefits. Consumers have the right to appeal decisions made by employer self-insured health plans, but in these cases, appeals must be made to the employer and are enforced by the U.S. Department of Labor.
The first step in appealing a health plan decision is a request for an internal appeal. The insurer must then conduct a full and fair review of its decision. If the case is urgent, the review process must be accelerated. When an appeal concerns urgent care, you may be able to have the internal appeal and external review take place at the same time. For internal appeals, a decision must be given within:
Individual insurance companies or policies may require more than one level of internal appeal before an external review can be requested. However, all levels of the internal appeals process must be completed within the timelines above.
If the internal appeal is denied, consumers may request an external review. The insurer must include information on the denial notice about how to request this review for plans that began on or after July 1, 2011. In an external review, the case will then be examined by an independent third party, and the insurer must comply with the review organization’s decision. This means that if the external reviewer approves an appeal, the insurer must provide the payments or services that were previously denied.
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