When a plan denies a claim, the member has the right to an internal appeal and then an external review by an independent party. Plans must give the reason for a denial and meet set timeframes at each step.
An independent organization, not your insurer, re-examines the denial and can uphold or overturn it. The insurer must accept the external reviewer’s decision by law, so it is effectively final. Federal external reviews are free; otherwise any fee is capped at $25.
You can appeal almost any denial of care you think should be covered, including “not medically necessary,” “experimental,” out-of-network, eligibility, or coverage-cancellation denials. Many can also go to an independent external review.
You have 180 days from a denial notice to file an internal appeal, and 4 months from a final denial to request an external review. Internal appeals are decided within 30 days (before care) or 60 days (after care); standard external reviews within 45 days.
Yes. In an urgent case you can file an expedited appeal and request an external review at the same time, without finishing the internal process first. Urgent internal appeals are decided within about 4 business days, expedited external reviews within 72 hours.
An internal appeal is asking your own insurer to reconsider a denial; an external review sends the dispute to an independent third party whose decision the insurer must follow. You usually complete the internal appeal first.
Ask your plan for a formulary exception or prior authorization with your doctor’s supporting statement. If the plan still denies it, you have the right to an internal appeal and then an independent external review.
An Explanation of Benefits (EOB) is not a bill: it shows what your provider charged, what your plan allowed and paid, and what you may owe. If a claim or prior authorization is denied, you have the right to an internal appeal with the plan and then an independent external review.
When you’re covered by two health plans, coordination-of-benefits (COB) rules decide which pays first (primary) and which pays second (secondary). The secondary plan doesn’t simply double your coverage; together the plans generally pay up to, not beyond, the allowed amount for a service.