Appealing Health Plan Decisions
You have the right to appeal a health insurance company’s decision to deny payment for a claim or to terminate your health coverage. The following rules for appeals apply to health plans created after March 23, 2010, and to older plans that have been changed in certain ways since that date.
You can appeal your insurance company’s decision through an “internal appeal”, in which you ask your insurance company to do a full and fair review of its decision. If your insurance company still denies payment or coverage, the law permits you to have an independent third party decide to uphold or overturn the plan’s decision. This final process is often referred to as an “external review”.
Your state may have a Consumer Assistance Program that can help you file an appeal or request a review of your health insurance company’s decision if you are not sure what steps to take. Your insurance company should have provided you with information about how to file an appeal and the appeals process when you were enrolled in coverage, and there may be information about the process on the plan’s website. Visit LocalHelp.HealthCare.gov to find help in your area.
Your internal appeals rights took effect when your plan starts a new plan year or policy year on or after September 23, 2010. Learn more here about internal appeals (appeals made through your insurance company).
If after an internal appeal the plan still denies your request for payment or services, you can ask for an independent external review. For plan years or policy years that begin on or after July 1, 2011, your plan must include information on your denial notice about how to request this review. If your state has a Consumer Assistance Program, that program can help you with this request. If the external reviewer reverses your insurance company’s denial, your insurance company must give you the payments or services you requested in your claim. Learn more about external review.
What This Means for You
If your insurance company denies payment for a claim or terminates your health coverage, you can request an appeal. When your insurance company receives your request, it is required to review and explain its decision. The insurance company must also let you know how you can disagree with its decision. It is required to start and complete the process in a timely manner.
If you don’t speak English, you may be entitled to receive appeals information in the language you speak upon request (Spanish and some other languages are available). This right applies to plan years or policy years that started on or after January 1, 2012.
Some Important Details
- Health plans that started on or before March 23, 2010 may be “grandfathered health plans.” The appeals and review rights don’t apply to them.
- Appeal rights depend on the state you live in and the type of health plan you have. Some group plans may require more than one level of internal appeal before you can request an external review.
For More Information
- If you have questions about internal appeals and external reviews, call your health plan or state insurance regulator.
- Find detailed technical and regulatory information on appealing health plan decisions.