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August 15, 2016
Under the Affordable Care Act’s expanded appeal rights it’s easier than ever to appeal a health insurance company denial, a Marketplace decision, or a SHOP decision.
Below we cover how to appeal a health insurance company decision in regard to cost sharing or coverage through internal and external appeals, how to get help appealing a Marketplace decision in regard to costs and coverage, and how to appeal decisions from the SHOP marketplace for small business.
If you don’t think the Marketplace made the right decision in regard to eligibility, income, exemptions, or another factor you can file an appeal.
You can appeal the following kinds of Marketplace decisions:
When you fill out an application with HealthCare.gov or your state’s Marketplace you’ll get a notice that explains what you qualify for and will include appeal instructions and the timeframe you have to appeal the decision. You can either file an appeal by yourself or get assistance filing an appeal from the Marketplace.
Make sure to hang on to your eligibility notice and keep in mind appeals can affect coverage of everyone on the plan. In some states appealing a Medicaid or CHIP appeal requires contacting your state Medicaid office (as explained in your eligibility notice).
In general, you can appeal by:
After your appeal you will receive a letter notifying you that your appeal was received and will explain what to do next. You may get a letter asking for more information. Typically appeals can take up to 90 days.
If an appeal would jeopardize your life, health, or your ability to attain, maintain, or regain maximum function you can request an expedited appeal. If the expedited appeal is accepted the Marketplace will rush a final decision as quickly as you specific situation requires.
Both employers and employees have rights in regard to appealing a decision made by the SHOP marketplace. Denial of eligibility and the SHOP not responding in a timely manner can both be appealed.
You can appeal by filling out one of the forms below.
Mail your completed appeals form to:
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0001
An authorized representative can file an appeal for you. You may also get help in alanguage other than English.
Learn about appealing a decision in the SHOP Marketplace for small businesses.
Call the SHOP Small Employer Call Center at 1-800-706-7893 (TTY: 711).Monday through Friday, 9 a.m. to 7 p.m. ET. Agents and brokers helping small businesses can use this phone number too.
Above we covered how to appeal an ObamaCare Marketplace decision below we cover how to appeal a decision by an insurer.
Before beginning the process of appealing to an insurance company, make sure you understand your following rights. You have:
(1) A right to information about why a claim or coverage has been denied;
(2) A right to see and respond to all information used in the internal appeal decision; and
(3) A right to an independent review (also called an external appeal).
Under the ACA consumers can appeal insurance company decisions to an independent reviewer and receive a response in 72 hours for urgent medical situations (unlike the standard appeal process which can take much longer).
In most cases you’ll first make an appeal to your health insurance provider and then rely only on an external appeal if your claim is denied. However, in emergency situations you should exercise your right to a rapid external appeal immediately.
Please see the external review process below to quickly understand how the appeal process works for urgent medical situations.
There are two different ways to appeal a decision by a health insurance company, an internal appeal and an external appeal. In most cases the proper course of action is to simply call your insurer and have an internal appeal done. If your claim is still denied then you move on to an external appeal of your claim. However in emergency situations you should take advantage of your right to a rapid appeal within 72 hours to ensure that you don’t go untreated due to a denied claim.
The information below is complied from HealthCare.gov and is meant to allow users to find all important appeal information in one place. HealthCare.gov is the official website for the Affordable Care Act. When in doubt call the Marketplace helpline for further guidance: 1-800-318-2596 / TTY: 1-855-889-4325
Internal appeal: If your claim is denied or your health insurance coverage cancelled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
External review: You have the right to take your appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.
There are 3 steps in the internal appeals process:
You file a claim: A claim is a request for coverage. You or a health care provider will usually file a claim to be reimbursed for the costs of treatment or services.
Your health plan denies the claim: Your insurer must notify you in writing and explain why:
You file an internal appeal: To file an internal appeal, you need to:
Complete all forms required by your health insurer. Or you can write to your insurer with your name, claim number, and health insurance ID number.
Submit any additional information that you want the insurer to consider, such as a letter from the doctor.
The Consumer Assistance Program in your state can file an appeal for you.
You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal.
If your insurance company still denies your claim, you can file for an external review.
Keep copies of all information related to your claim and the denial. This includes information your insurance company provides to you and information you provide to your insurance company like:
You can file an internal appeal if your health plan won’t provide or pay some or all of the cost for health care services you believe should be covered. The plan might issue a denial because:
In urgent situations, you can request an external review even if you haven’t completed all of the health plan’s internal appeals processes. You can file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function. You may file an internal appeal and an external review request at the same time.
A final decision about your appeal must come as quickly as your medical condition requires, and at least within 4 business days after your request is received. This final decision can be delivered verbally, but must be followed by a written notice within 48 hours.
There are 2 steps in the external review process:
You file an external review: You must file a written request for an external review within 60 days of the date your insurer sent you a final decision. Some plans may allow you more than 60 days to file your request. The notice sent to you by your health insurance issuer or health plan should tell you the time frame in which you must make your request.
External reviewer issues a final decision: An external review either upholds your insurer’s decision or decides in your favor. Your insurer is required by law to accept the external reviewer’s decision.
Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan
Any denial that involves a determination that a treatment is experimental or investigational
Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage
Insurance companies in all states must participate in an external review process that meets the consumer protection standards of the health care law.
State: Your state may have an external review process that meets or goes beyond these standards. If so, insurance companies in your state will follow your state’s external review processes. You’ll get all the protections outlined in that process.
Federal: If your state doesn’t have an external review process that meets the minimum consumer protection standards, the federal government’s Department of Health and Human Services (HHS) will oversee an external review process for health insurance companies in your state.
Depending on your plan and where you live, the following may apply to you:
Standard external reviews are decided as soon as possible – no later than 60 days after the request was received.
You may appoint a representative (like your doctor or another medical professional) who knows about your medical condition to file an external review on your behalf. An authorized representative form is available at: www.externalappeal.com
If your health insurance company is using the HHS-administered external review process, there’s no charge. If your issuer has contracted with an independent review organization, or is using a state external review process, you may be charged. If so, the charge can’t be more than $25 per external review.
If you need help filing an internal appeal or external review, your state’s Consumer Assistance Program (CAP) or Department of Insurance may be able to help you.
Contact HealthCare.gov for more information.
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