What is an Appeal?

Insurance claims can be challenging and confusing to navigate. The following tips will help you learn more about what an insurance appeal is and what it means to file an appeal.

As many know, we rely on our insurance company to cover the cost of medical procedures. However, there are times when an insurance company may deny a claim, either before the procedure takes place or after, leaving a person responsible for paying for the procedure. When this happens, a person has the right to file an appeal with their insurance provider. Below are some tips on different types of appeals that can be filed and when to file these appeals.

1. It is important to be sure to document any contacts that you have when filing an appeal. Keep a paper and pen nearby and document the dates you called, who you spoke with and what was discussed. It is important to keep records of all of the details so that you can look back on this information at a later date, if needed.
2. When it comes to insurance appeals, there are two different types of appeals. There are internal appeals and external appeals. Internal appeals usually come first, and these are appeals that you file with the insurance company directly. External appeals (which are also sometimes called external medical review/ independent medical review) are filed with an outside agency later, if your insurance company denies your internal appeal.
3. Within an internal appeal, there are different types of appeals that can be filed, and this will depend on your specific situation.
   1. Pre-authorized denial is when you have submitted a medical procedure to your insurance BEFORE the procedure takes place, and you are waiting for them to approve the procedure before you go forward with the procedure. If you submit a procedure to insurance and they deny it, you can then file an appeal and the insurance company must give you an answer within 30 days of the appeal.
   2. There may also be times where you may have a procedure without getting insurance approval first and then after the fact you find out that your insurance denied the claim, leaving you responsible with the bill. If you appeal this denial, then it would be an appeal for a procedure that already took place, and the insurance company has to give you an answer within 60 days.
   3. An urgent or expedited appeal CAN be filed (for a pre-authorization) if you need a procedure ASAP and a delay in the procedure can seriously jeopardize your health.
4. If you do not get the result that you hoped for, and your insurance company denies your internal appeal, you can then go ahead and file an external appeal. It is important to note that under the affordable care act, the ability to file an external appeal is available in every state. These external appeals are USUALLY free but at times there can be a fee. If there is a fee, each state is not allowed to charge more than $25.
5. When filing an external appeal, it’s also important to note that the rules are different for Medicare/Medicaid/Tricare.
6. To move forward with an external appeal, you are going outside of your insurance company, in order to have an independent reviewer look at your case. If your independent reviewer deems that the medical procedure is medically necessary, then they will approve your appeal. If your appeal is approved, then your insurance company will be mandated to cover the cost.
7. When filing an external appeal, the decision is made within 45 days. There is a way to file an urgent appeal, which has a 72-hour turnaround time.
8. There are certain situations where an internal and external appeal can be filed at the same time, in order to ensure a quick response.

If you or someone you know is struggling with health insurance click here and Sharsheret Insurance Advocacy CareLine can help.

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