• What Happens if I’m not happy with a Health Insurance Claim Decision?

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    There may come a time when you submit a health insurance claim and you’re not happy with the decision made by the insurance provider.  But what can you actually do about it?

    There are a number of reasons why an insurance provider might turn down your claim, such as insufficient need for treatment, or questions over whether the area of treatment is covered by your policy.  Whatever the reason it’s not ideal for you if you end up being presented with a large bill for treatment.

    Prior to the implementation of the Affordable Care Act appealing a decision could be something of an unknown quantity. You might pick up a phone to call the provider and not even be aware that you’re actually starting a formal appeal process. This has all changed, as there are now procedures to be followed by all health insurance providers. You can learn more about the health insurance policies offered by HBF by following this link.

    What are these procedures?

    There are two types of appeal that are possible; internal appeal, and external review.  When an internal appeal takes place the insurance provider looks at the decision again and checks whether or not it is correct.  When an external review takes place the decision is considered by a third party who looks at whether the appeal decision was correct. There are procedures in place for both of these circumstances.

    Internal Appeal

    If you’ve received a decision that you’re unhappy with you need to appeal to the insurance provider within 6 months of receiving the original decision.  If you need help with the appeal you should speak to your local Consumer Assistance Program who can submit it for you.  To submit the appeal you need to either complete the forms your provider requires or write to them with your name, heath insurance id number, and the claim reference number.

    You should include anything that you want to be considered as part of the appeal, such as a doctor’s letter.  Remember that you should keep copies of all the documentation including the original decision, your appeal request and any supporting documentation.

    There are several different types of decision that you can appeal:

    • Benefit not covered by plan
    • Health care provider not in the plan’s network
    • Treatment not medically necessary
    • Claim irregularities

    Your appeal must be decided within 30 days if you’ve not yet received the treatment and within 60 days if you’ve already had the treatment.  The health insurance provider must give you their decision in writing.  If, after reconsidering your case, the provider still refuses your claim you can ask for an external review.

    External Review

    As for the internal appeal, there are procedures to follow for an external review.  You must submit your request in writing within 60 days of receiving the appeal decision.  Sometimes your plan will allow more time than this; you’ll need to check. The third party reviewer will then review the decision and provide you with a response within 60 days of your request.

    Who deals with your request depends on whether or not your state has a provision that complies with consumer protection requirements.  If they don’t then your review will be considered at federal level.

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