2 NAIC / UNDERSTANDING HEALTH CARE BILLS: HOW TO APPEAL DENIED CLAIMS
· Ask your health plan how to file an internal appeal by contacting the
customer service number provided on your insurance card /materials,
or
· Write a letter to your health plan requesting an internal appeal. Make
sure to include your name, claim number, and health insurance ID
number. You should include any additional information, such as a letter
from your provider, that helps support your claim. (See next page for
sample letter.)
Upon receiving your request, your health plan has a specific amount of
time to review and issue a decision on the internal appeal.
. . . If Your Health Plan Still Says “NO”
Filing an External Review
If your health plan does not change its decision as a result of the internal
appeal, an external review can be requested. An external review is
performed by an independent review organization. You must ask for
an external appeal within a specific amount of time after receiving the
decision of your internal appeal.
· Your internal appeal notice should provide information on requesting
an external review.
· Your state’s insurance regulatory agency is usually in charge of the
external review process.
· New information can be submitted to support your position.
· The external reviewer will provide you and your health plan with
written notice of its decision within a specific amount of time after
receiving the review assignment.
· If the external review results in a reversal of your health plan’s decision
to deny, the company must approve benefits for the covered services.
If you have questions or think your health plan is doing something wrong,
contact your state insurance regulatory agency. A directory of all state
insurance regulatory agencies is available at naic.org.