Has your health plan denied payment for a service or treatment? You have the right to appeal the decision. New rules spell out how your plan must handle your appeal (usually called an "internal appeal"). If your plan still denies payment after this first appeal, you have the right to let an independent review organization (IRO) decide whether to uphold or overturn the plan's decision. This final check is called an "external review."
Here's what's different
Under the law, there is now a standard internal review process for all health plans. Also, all health plans must offer you an external review if your treatment or service was denied through the plan's internal review process.*
How it impacts you
Here's an example of when an internal appeal or external review is available, and a description of what happens after a decision has been made:
If your plan denies coverage of a test, such as an MRI, you and your doctor can appeal that decision to your plan. If the plan still refuses to cover the test, you can appeal to an external reviewer. If the external reviewer agrees with your appeal, your insurer must pay for the test.
Can I get help filing an appeal or requesting a review?
Yes. Your state may have a health care Consumer Assistance Program that can help you file an appeal or request a review. To find out if your state has this program, please call the Employee Benefits Security Administration, U.S. Department of Labor, at 866-444-3272
What happens if my plan denied my appeal for payment or services?
Your plan must include information on your denial notice about how to request an independent external review. If your state has a Consumer Assistance Program, that program can help you with this request.
If an external reviewer overturns my plan's denial, what happens then?
Your plan pays for the service(s) provided and billed on the claim you appealed.
How long does an internal appeal take?
When you request an internal appeal, your plan must give you its decision within:
- 72 hours after receiving your request when you're appealing the denial of an urgent care claim. If your appeal concerns urgent care, you may be able to have the internal appeal and external review take place at the same time.
- 30 days for denials of non-urgent care you have not yet received.
- 60 days for denials of services you have already received.
*Have health insurance under a grandfathered plan? If so, you might not get these benefits. If there is any difference between the information on this website and your health plan, your policy's provisions will apply.