When your health plan refuses to pay a claim or terminate your coverage, you have the right to ask your health plan to reconsider its decision. Your health plan is required to inform you why they’ve denied your claim or terminated your coverage. Also, your health plan must notify you of your appeal rights and provide steps on how to file an appeal.
The internal claims appeal process is also known as a grievance procedure. In this process you may ask your health plan to conduct a full and fair review of its decision. An internal appeal must be filed within 180 days (six months) of receiving notice that your claim for a treatment or service has been denied.
Your health plan must provide you with a written decision regarding your internal appeal. If you have an urgent care situation, an expedited internal appeal can be requested. An expedited internal appeal requires your health plan to notify you of its final decision as quickly as possible.
An external review can be requested if your claim is still denied after an internal appeal. A written request for an external review must be filed within 120 days (four months) of a claim denial. You can submit additional information to support your appeal. Any information you submit will be reviewed along with information you submitted on your application. Your health plan will determine if the request is eligible or ineligible for an external review and will notify you of its decision within five business days of receiving the request.
An expedited external review can be requested if the timeline for the standard external review would seriously jeopardize your life or your ability to regain maximum function. In this case, your health plan must immediately determine if your request is eligible or ineligible.
External reviews are conducted by state-licensed entities known as an independent review organization (IRO). The IRO assigned to your appeal will either uphold or reverse the claim denial and will notify you, your health plan and the Insurance Commissioner of its decision. If the IRO decides in your favor, your health plan must immediately approve the claim.
IRO Timeline: An IRO will make its final decision within . . .
- 45 days for a standard external review
- 72 hours for an expedited external review
- 20 days for an experimental or investigational review
- 48 hours for an expedited experimental or investigational review