THE APPEALS PROCESS

WHAT HAPPENS WHEN YOUR HEALTH INSURANCE COMPANY SAYS NO

Adapted from a publication of the Colorado Department of Regulatory Agencies

Colorado Division of Insurance

SELF INSURED PLANS

Under a federal law known as ERISA, state insurance laws do not apply to self-insured health plans. Most large corporations and businesses offer some plans that are self-insured. Some use a health insurance company to handle claims, so you may not know that your health plan is self-insured. To find out, contact your employer’s human resources department. All self-insured plans are required to have some type of appeal procedures. The following information applies to State of Colorado health insurance plans only. About 30 percent of Colorado’s group health plans are commercial or State of Colorado plans.

QUESTION: What happens if my health insurance company denied my request to see a specialist or to have a medical procedure?

ANSWER: You have the right to challenge the decision any time your health plan denies coverage for services that you and/or your doctor feel are medically necessary.

Most health plans have a medical professional that reviews your doctor’s or other health care provider’s request for care and services to ensure it is a covered benefit and that it is medically necessary and appropriate. This is referred to as “utilization review.”

STANDARD AUTHORIZATIONS

QUESTION: What happens if my doctor requests pre-approval for a hospital admission, procedure or service?

ANSWER:

• Your health plan has 2 business days after receiving all information from your doctor to make a decision to approve or deny the request.
• The plan must notify your doctor of the decision to approve or deny your request within 1 working day by phone and notify you by fax or in writing.

QUESTION: What happens if the plan denies my doctor’s request?

ANSWER:

• The plan must write, fax or e-mail you within 1 working day after making the decision.
• The notice of denial must include the main reasons for the refusal to pay for the treatment, how to initiate an appeal, and how to request a written statement of the clinical criteria used in the decision.
• Your doctor has the right to talk to the plan doctor involved in the denial. Your doctor may ask for reconsideration of the decision, either orally or in writing. The health plan must make a decision within 1 working day after receiving this new request.

QUESTION: What happens if I am in the hospital or receiving treatment, and my doctor asks for an extended stay or additional services?

ANSWER:

• Your health plan has 1 day after receiving all information to make a decision and another day to call your doctor by phone.
• The plan must tell you about their decision within 2 working days by letter, fax or e-mail.
• This written notification must include:

ü The date of admission or when the service started.

ü The number of extended days in the hospital, or the next review date, or the new number of days or services or services approved.

QUESTION: What if my plan denies the doctor’s request for an extended stay or additional services?

ANSWER: The health plan must cover your hospital stay or treatment until you and your provider have been notified of the denial.

QUESTION: What happens if I submit a claim for care or services already received?

ANSWER:

• Your health plan has 30 days after receiving all information to review the service and determine whether or not it was medically necessary.
• If the claim is denied, the plan has 5 working days after making its decision to tell you and your doctor in writing. The letter must include:

ü The reason for denial.

ü How to appeal the decision.

ü How to request a written statement giving the medical reason for the denial.

ü

QUESTION: What happens if there is an emergency and I don’t have time to get pre-authorization for care, or if I have to go outside the network for care?

ANSWER:

EMERGENCY AUTHORIZATION

Plans cannot require prior authorization for emergency services if you have a good reason for believing a life or limb-threatening situation exists. In an emergency situation you can go to a non-plan emergency room if going to a plan facility would delay treatment and worsen the situation.

Your health plan must pay for services necessary to evaluate and stabilize you, even if the screening finds no emergency actually existed, if a reasonable person would have believed there was an emergency.

QUESTION: What happens if I believe I have been inappropriately denied a benefit?

ANSWER:

APPEALS PROCEDURES

If you are not satisfied with your health plan’s decisions, you have the right to appeal. All health plans must have written procedures for dealing with appeals. Most plans require that the request be in writing. For details, check your membership booklet or policy under “Grievance Procedures.”

STANDARD APPEALS

Following are some things you should know about the Colorado required two-level appeal system for denial of coverage:

FIRST LEVEL APPEAL

Important Note! As of 2004, the notification and the deadlines are set by the Division of Insurance. The above rules for notification are only for denials based on medical necessity. The first level appeal shall be a review by a physician who shall consult with an appropriate clinical peer or peers in the same or similar specialty of the case. A health plan may establish an internal review process that eliminates the first-level review and have all appeals sent directly to a review panel.

Your appeal must be evaluated by a doctor who was not involved in the first decision to deny your claim.

The plan’s letter telling you of the appeal decision must be sent to you within 20 days of the appeal request. The letter must include:

ü The name, title and qualifications of the doctor who evaluated the appeal.

ü The reviewer’s statement of the reason for the appeal.

ü The medical reason for the decision.

ü How to file a second level appeal.

SECOND LEVEL APPEAL

Important note! As of 2004, the second level review panel is established by the health plan. The panel may be composed of employees of the health plan who have appropriate professional expertise. The health plans interpret “appropriate expertise” to include employees from sales due to their expertise in benefits. Panel members can have previous involvement with the grievance. The review panel can have members that have direct financial interest in the case or the outcome of the review.

If you are not satisfied with the first level appeal decision you can request a second level appeal as described below:

• (Note: this rule has changed-see note above) The health plan must appoint a second level grievance review panel of at least three people. A majority of the members must be professionals with the appropriate expertise who were not involved in the original denial, are not employees of the health plan, and do not have a direct financial interest in the outcome. As stated above, this rule is changed!
• The panel must hold a meeting to review your second level appeal within 45 days of your appeal request.
• You have a right to, but need not appear in person before the panel. If you live too far away, the plan must pay for you to present your case by conference call, video conferencing, or other technology.
• You have the right to present supporting material in writing before and at the hearing. You also have the right to be assisted by a person of your choice.
• You must be notified in writing of the review date at least 15 working days beforehand.
• If you decide to have an attorney present, you must call or write the insurance company 5 working days before the review.
• If the plan intends to have an attorney present, the plan must notify you 15 working days before the review.
• The health plan must provide you with all relevant information that is not confidential.
• The plan must notify you of the panel’s decision within 5 working days of the review meeting. The letter must include:
1. The names, titles, and credentials of the panel members.
2. Panel members’ summary of the reason for the decision, including reference to any evidence or documents considered by the panel.
3. The medical reason for the decision.
4. Notice of any additional appeal rights, including your right to contact the Colorado Division of Insurance.

MEDICARE AND MEDICAID

Medicare has a different set of rules for appeals. The above requirements do not apply. Call the Division of Insurance to find out about Medicare’s rules at 1-800-930-3745.

People on Medicaid have different appeal rights. Call Medicaid or refer to the section about Medicaid Appeals in the table of contents.

QUESTION: What happens if I need an immediate response to my appeal?

ANSWER:

FAST TRACK APPEALS

All health plans have special procedures for appeals that need immediate attention. Fast track appeals are appropriate when the normal review time frame would seriously jeopardize your health or ability to recover.

• Fast track, or expedited appeals, must be evaluated by doctors in the same or similar specialties who have not been involved in the initial denial of care.
• Plans must notify you and your doctor of their decision within 72 hours.
• If the review is held while you are in the hospital, the plan must cover your stay until you receive notification of the decision.

QUESTION: What if I have a complaint with my health insurance or the network providers that is about service, such as quality or timeliness?

ANSWER:

OTHER TYPES OF GRIEVANCES

If you have a complaint that deals with a problem other than denial of coverage, call your plan’s customer representative and ask how to register your complaint. For example, if it takes you too long to get an appointment with your doctor you could call your health plan to complain. In many plans, the grievance procedures will be the same for both coverage denials and other types of complaints. Some plans may have different procedures to handle different types of problems.

QUESTION: What role does the Division of Insurance play in the appeals process?

ANSWER:

WHEN THE DIVISION OF INSURANCE CAN HELP YOU

If you have completed your health plan’s first and second level appeals and you are still not satisfied, you can contact the Colorado Division of Insurance. You are also welcome to contact the Division for clarification of the process.

File a complaint by writing a brief letter stating the facts of the case and sent the letter to:

Colorado Division of Insurance

1560 Broadway, Suite 850

Denver, Colorado 80202

Phone: (303) 894-7490

1-800-930-3745

It is important for you to complete your insurer’s appeal process before contacting the Division of Insurance with your complaint, unless it is for clarification of your rights. If you have not completed this appeal process, the Division will refer you back to your plan.

The Division of Insurance can help you…

• Record your complaint against the health plan.
• Thoroughly investigate your complaint.
• See that you get clear answers to your questions.
• Make sure the health plan follows state law.

The Division of Insurance cannot…

• Force a favorable decision if the law and facts are not on your side.
• Require your plan to pay for services that are excluded by the policy.
• Provide legal services that are sometimes needed to settle complicated problems.

EXTERNAL REVIEW

Effective June 1, 2000, if you are not satisfied with the second level decision, you can apply for an independent external review within 60 days of the final health plan denial. An independent external review entity (currently a function of the Colorado Division of Insurance) will be assigned by the Division of Insurance. The external review findings will be provided within 30 working days and will be binding on both the carrier and the consumer.

TIPS FOR THE SAVVY CONSUMER

FROM THE COLORADO DIVISION OF INSURANCE

Read your policy or membership booklet carefully. The key to getting quality health care is being an educated consumer.

If you believe you have been wrongly denied coverage, create a paper trail by organizing the following:

Ø Your policy.

Ø Copies of denial letters.

Ø Copies of any correspondence with your health plan.

Ø Detailed notes of conversations.

Ø Copies of any correspondence between you doctor and the health plan concerning your problem.

In all correspondence, include:

Ø Your name, address, and telephone number.

Ø Policy number.

Ø Type of policy.

For all phone conversations, keep a written record of:

Ø The date and time of your call.

Ø Name of the person you talked with.

Ø What was discussed during the call.

Send a copy of any letters to your employer’s benefits manager or human resources director. Your company is interested in your health and your satisfaction with the health plan. The benefits manager may have some leverage with the health plan, since employers can consider switching health plans if there are enough complaints.