How long does an insurance appeal take
You must submit a request for an independent medical review within six months of receiving the last determination letter from your insurer. This deadline may be shorter if you are insured through your employer and the plan is “self-insured.” You should check with your employer for more information. You must determine where to file your independent medical review. This determination depends on what type of plan you have. HMOs, PPOs, and Specialized Plans. The California Department of Managed Healthcare (“DMHC”) regulates all health maintenance organizations (HMOs), some preferred provider organization (PPO) plans, as well as specialized plans that cover only certain kinds of care, such as certain dental and vision care plans, behavioral or mental health plans, and chiropractic plans.[6] If you need help figuring out if DMHC regulates your plan, you should visit www.hmohelp.ca.gov or call DMHC at 1-888-466-2219. If your plan is regulated by the DMHC, you should submit a request for an independent medical review here. You should include any new information and documentation with your application. You can also print a copy of the application and fax it to (916) 255-5241 or mail it to: Help Center Fee-for-service plans and PPOs. The California Department of Insurance (“CDI”) regulates indemnity health insurance plans, also known as fee-for-service plans, and most PPO plans.[8] You can call the CDI at 1-800-927-4357 to find out whether it regulates your specific plan. If your plan is regulated by the CDI, you should apply for an independent medical review here. You should include any new information and documentation with your application. You can also print a copy of the application and fax it to (213) 897-9641 or mail it to: Department of Insurance, Health Claims Bureau Self-funded plans. If you receive your health insurance through your employer, check with your employer to see if your plan is “self-funded.” Neither DMHC nor CDI regulate these types of plans. If your plan is a self-funded employer plan, ask your employer to provide you with the contact information for the plan’s administrator to find out what your independent review options are. Expedited independent medical review requests. If you seek an expedited independent medical review, ask your health care provider to certify, in writing, that a delay in receiving the requested treatment or service would create a serious and imminent risk to your health.[9] Insurer’s responsibility. If your request for an independent medical review is granted, your health insurer has 24 hours to provide the necessary documentation and information to the independent medical reviewer.[10] If Your Insurance Provider Denies a Claim, You Have the Right to File an Appeal When you receive medical services, your medical provider will submit a request for payment for those services to your health insurance provider (called a claim). Your insurance provider might deny all or partial coverage of the claim. If this happens, you can file an appeal. An appeal is a request to review a health insurance provider’s decision regarding a claim. The process of filing an appeal can seem daunting. But it is both your right and in your best interest to appeal a denied claim that you and your healthcare team deem important for your health. In 2019, 40.4 million health insurance claims were denied and only .02% of those denied claims were appealed (Pollitz, 2021). This equates to only 63,318 appeals of 40.4 million denied claims. Yet, people who do file an appeal often see results in their favor: “It is absolutely in somebody’s best interest to try and appeal, because we know somewhere between 40% and 60% of all appeals are decided in favor of the patient,” notes Monica Bryant of Triage Cancer. This blog offers tools, advice, and guidance to empower patients who need to file a health insurance appeal for a denied claim.
Before filing an appeal, it is helpful to understand the different types of insurance appeals:
An internal appeal is where you go back to your insurance company (individual or funded plan) or your employer (self-funded plan) and ask them to reconsider their decision. Appeals can take place after you received a service or before you receive a service. You have 6 months (180 days) from the day you learn your claim was denied to file an appeal. Your insurance company then has a set timeline to respond back. You can also file an expedited appeal, for example, if waiting for an extended period of time could cause more harm. An external appeal can be filed if your insurance denies your original appeal. In this case, you go to an independent entity and ask them to look at the facts. This process is based on your state’s specific laws, and the decision at this step is final in all cases. Generally, you have 4 months from the day you learn your claim was denied to file an external appeal. You can also file an expedited appeal, if you qualify. An expedited appeal is useful when the time needed for a standard appeal could harm your health. With this type of appeal, you can file both internally and externally at the same time, if the case permits.
Prepare to File an Appeal Step 1: Determine the type of plan you have. Knowing what type of insurance plan you have will help inform the steps you will take when you file an appeal. Types of plans include:
Need help determining what type of health insurance plan you have? Triage Cancer provides a questionnaire to help you identify your plan. Or, contact your state’s Department of Insurance to find out what kind of plan you have. Step 2: Understand the reason for a denial. Here are some examples that may explain why your claim was denied. There may be other reasons not listed here.
Step 3: Gather evidence to prove that the treatment or service is medically necessary. Work with your medical team to illustrate the need for the treatment or service. This can include a letter from your provider, your medical records, and medical literature to support the medical effectiveness for a specific treatment. Tip 1: When filing an appeal, use a spreadsheet or form to keep track of all your correspondences. This will help keep you aware of what has been completed and what needs to be done. Tip 2: Organize all correspondences, notes, copies, and records in one place so that you can quickly reference information about your appeal. Get Help With the Appeals Process If you receive a health insurance claim denial, you can contact your state’s Department of Insurance to help point you in the right direction. They can let you know who you can reach out to for assistance with filing your appeal. Find the contact information for your state’s Department of Insurance.
State Departments of Insurance are also the entities that typically conduct external reviews, should you have to file an external appeal. They may also be able to help you determine if your appeal is eligible for an expedited process. For additional guidance, Triage Cancer offers resources to help demystify the appeals process. Get Help With Your Health Insurance Questions We are here to support you. If you have questions about health insurance or other concerns about the cost of cancer care, we can help. Call our Cancer Support Helpline at 888-793-9355 to talk with an experienced patient navigator.
Editor's note: On April 25, our Cancer Policy Institute hosted “Health Insurance Appeals 101,” a webinar about the insurance appeals process. This webinar was part of our Forum on Utilization Management, which was created to bring patient advocates together for meaningful conversations, ask tough and nuanced questions, and identify new ideas and practices that optimize evidence-based healthcare. Speakers Monica Bryant of Triage Cancer, Mary Kwei of the Maryland Insurance Administration, and Aimee Hoch of the Cancer Support Community spoke about what patients and caregivers should know about the insurance appeals process. Monica, Mary, and Aimee highlighted resources that will assist in filing an insurance appeal. |