Medical drama is no fun (aside from “Grey’s Anatomy,” of course), and nothing makes me sick to my stomach more than the thought of my health insurance claim getting denied. Bearing the burden of big bills is awful enough, but doing it when you’re sick? Ick.
Good news though: You have options. The Affordable Care Act (aka Obamacare) gives policyholders the right to appeal denied health insurance claims if their insurer refuses to pay. Here are the steps you need to take if you get stuck with a denied claim.
Let’s start from the beginning of this saga, shall we?
So, your health insurance claim got denied.
If you’re thinking “um, wait why??” it could be for a number of reasons.
According to HealthCare.gov, your health plan might deny a claim because:
- The benefit isn’t offered under your health plan.
- Your medical issues began before you joined the plan.
- You received out-of-network health services.
- The requested service or treatment isn’t “medically necessary.”
- The requested service or treatment is “experimental” or “investigative.”
- You’re no longer enrolled or eligible to be enrolled in the health plan.
- It’s revoking or canceling your coverage going back to the date you enrolled because the insurance company claims that you gave false or incomplete information when you applied for coverage.
Also, your health insurer has to notify you within a specific time frame explaining why you’re getting denied. Because ghosting you just isn’t going to fly.
They must notify you:
- Within 30 days for medical services you’ve already received.
- Within 15 days if you’re seeking prior authorization for a treatment.
- Within 72 hours for urgent care cases.
Now, it’s time for you to take action. Don’t drag your feet with this; you have 180 days (six months) from receiving notice that your claim was denied to file your appeal. To actually file the appeal, you need to fill out all the forms required by your insurer, which will likely include producing important paperwork like explanation of benefits, or EOB, forms or a letter from your doctor. Be sure to keep copies of these! The Consumer Assistance Program, which is available in many states, can file the appeal for you.
Once you’ve filed your appeal, your insurer can’t just leave you hanging. Your insurer must complete your internal appeal within 30 days for a service you haven’t received yet, or within 60 days for a service you’ve already received.
If your internal appeal still gets rejected (RUDE!), you have the option to file an external review. It’s a headache, I know, but if there’s a chance you can get those medical bills paid off, it’s worth all that #adulting.
External reviews are conducted by an outside party, and they can be requested if your insurer denies your appeal for a variety of reasons, like if the treatment is experimental or investigational.
Under Obamacare, insurance companies in all states must participate in the external review process that meets certain consumer protection standards, and they must be completed within 60 days after the request is received. HealthCare.gov fleshes out a few more deets about your rights when it comes to external reviews.
BTW, in most cases, your external review process will be free. But there could be a small fee, no more than $25, depending on your issuer.
Your external review is the last step you can take, and whether the outside party decides to either uphold the insurance company’s denial of your claim or reverse it, your insurer must accept it. The process of appealing a claim can definitely be dizzying, so don’t be shy about reaching out to consumer assistance programs for help!