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Feb 2016

Patients vs. Health Plans: A Right to Fight

Denial, denial, denial. When health plans don’t reimburse, you don’t have to accept it.

Most patients have always had the right to appeal a health plan’s decision to deny coverage. However, under the Affordable Care Act (ACA), a patient now has the right to appeal when a health plan denies reimbursement for medical services or terminates coverage.

The following ACA rules for appeals apply to health care plans effective after March 23, 2010. If your plan began prior, it has been “grandfathered” in and is exempt from certain rules, but may lose that grandfathered status if it makes major changes to benefits and costs to enrollees.

How can a patient submit an appeal?

  • Internal appeal: A patient may appeal a health plan’s decision through an “internal appeal.” This is a process in which you ask your insurance company to do a full and fair review of its decision. Your appeal should always be submitted in writing (and you should retain a copy for yourself!). When the health plan receives your request, it is required to review and explain its decision.  The health plan must also let you know how you may disagree with its decision. The plan is required to start and complete this process in a timely manner.
  • External review: If the health plan still denies payment or coverage, the ACA permits the patient to have an independent third party uphold or overturn the plan’s decision. This final process is often referred to as an “external review.” For plan years or policy years that begin on or after July 1, 2011, a health plan must include information on your denial notice about how to request this review. Note that some group plans may require more than one level of internal appeal before you can request an external review.

Many states have agencies that will help patients file an appeal or request a review of their health plan’s decision. A health plan should also provide its patients with information about how to file an appeal if a claim is denied. There may be information about the appeals process and deadlines on the plan’s website. The federal government’s website is also a fantastic guide to where to turn for help.

So the next time you receive a denial, don’t forget about a patient’s right to fight.

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