July 13, 2020

Best Practices - Insureds
Appeal the Claim  

1. Know your coverage - Before you call customer service or request an internal review, make sure you know what your health plan does and does not cover -- and what procedures you must follow in order to get coverage in the first place.
2. Call Customer Service 

- If you disagree with a health plan charge or coverage decision, you should start by calling customer service. Customer service agents may be able to reverse an erroneous charge or approve services that were originally denied.

Know the Appeals Process - An internal appeal is a first request to have your healthcare plan reconsider your claim after it has been denied. Under the terms of some health plans, you may also have to request a second-level internal review.
Once you have exhausted the internal appeal process that is determined by your healthcare plan, you can request an external appeal. In an external appeal, your claim goes for an independent review of the denied claim. An independent clinical reviewer who is not employed by your health plan conducts the review. Independent reviewers include board certified or licensed physicians, physician advisors, allied clinicians, and other healthcare professionals.


4. Prepare for Internal Appeal -  Assemble d

ocuments such as the

criteria that the insurance company used to base its decision, treatment notes and any research to support the opinion that the denial should be overturned Put together a


ontact log showing the type of contact you made including the telephone number, the date, who you talked to, what was said. Also organize p

ersonal Information such as p

atient contact information, contact information for the person representing, name of the insurance company, policy number and claim numbers, name of employer, names of doctors

  • 5. File a Timely Internal Appeal - Don't blow the filing deadline, and be sure to include all supporting documents:

  • additional research on your medical condition (including treatment guidelines and medical journal articles)
  • additional research on the cost-effectiveness of the applicable treatment or procedure, and
  • evidence of payment (for billing disputes).
  • letters from your doctors (i.e. explaining why certain treatment or procedure should be covered)
  • second opinions (opinions from doctors other than your own as to what treatment or procedure is necessary)
  • explanation of benefit (EOB) forms applicable to your claim
  • references to the applicable sections of the Evidence of Coverage
  • 6. Prepare External Review -  If your internal appeal is denied (receives an "adverse" decision), the next step is an external reviewappeal process. For fully-funded plans, your state regulates external appeals. For self-funded plans, ERISA under the Department of Labor (DOL) regulates external appeals.In both cases, however, an independent review organization (IRO) handles the review itself.Depending on whether you are insured under a fully-funded or self-funded healthcare plan, different laws regulate the external  
    In most states, the review panel does not conduct a hearing. Instead, you must submit all your evidence and arguments in writing. Be sure to read the external review requirements carefully and submit everything that is requested. An external review is usually administered by the Bureau of Insurance. The Bureau assigns your case to an independent reviewer (not associated with the insurance company) The independent reviewer hires a health care provider who is an expert on the medical issue being decided.


  • File External Review If Allowed by the Plan -To find out about an independent external review, check your health plan benefits booklet (sometimes referred to as “Evidence of Coverage”), which in some states is required to inform health plan members about appeals options external to the health plan. Another important resource is your state’s insurance department, or agency. Or Arbitration. Some health plans offer arbitration, in which an independent third party reviews the dispute and recommends an outcome. Whether the arbitrator's ruling is binding depends on the state and the health plan.If arbitration is offered under an employer-provided health plan, federal law says you can't be charged for using it. 


    Related Resources:
    1. "Health insurance claim denied? Appeal, appeal, appeal" Michelle Andrews, L A Times, (June 23, 2011)

    Welcome to the American health insurance industry. Instead of helping policy holders attain the health security they need for their families, big insurance companies get rich by way of medical denial letter to patients with coverage. In 2009 they were sending lobbyists to Washington, DC to twist the arms of lawmakers to oppose reform of the status quo. Why? Because the status quo pays.