If you have exhausted all the appeals available with your insurance company, depending on which state you live in, you may be able to have your claim reviewed by an external appeals review board. Your insurance company will notify you that your appeals have been denied. This document is usually called a notice of "adverse determination" or "adverse decision”. In this notice, the insurance company will most likely provide instructions on how to file for an external appeal and the deadline for filing an external appeal.
The external appeals review board usually is an independent panel outside of the insurance company. This is an objective group that will review the insurance company’s decision. In most states, state external review requirements apply to all types of health plans. However, there are some plans that are not eligible for external review.
Exceptions for External Review:
- In a few states, external reviews apply only to managed care plans (such as HMOs, PPOs or POS plans), or just to HMOs.
- If you are part of an employer sponsored self-funded plan, your state’s external review (appeal) laws do not apply. To appeal the decision, contact the individual in your human resource department that makes decisions regarding benefits selections.
- State external reviews (appeals) do not apply to Medicare and Medicaid beneficiaries. If you are a Medicare patient, refer to the review process described in your Medicare Handbook. If you are a Medicaid patient, contact your state or local Medicaid office about the appeal process.
If the external review rules in your favor, the decision is binding on your health plan, meaning the insurance company will need to cover the procedure or service.
The Kaiser Family Foundation site provides information about the external appeals process for each state. This is a great resource to learn more about who to contact and the details of the process in your state. http://www.kff.org/consumerguide/states.cfm.