Brian White | June 5, 2018 | Insurance Claims
As a claimant involved in the health insurance claim appeals process, your future could be up in the air. One thing that can help you feel more grounded is knowing how long the process might take.
While every appeal is unique, you can estimate the timeline for your claim by looking at similar cases and understanding the steps an appeal takes. Expedite the appeals process as much as possible by retaining an injury lawyer to handle the legwork of your claim. A lawyer can help you recover the compensation you need to move on after an accident.
Two Types of Health Insurance Appeals
The Affordable Care Act (ACA) gives claimants two main options for the appeals process: an internal appeal and an external review. An internal appeal is generally the first step one will take in an effort to get the insurer to change its mind. An internal appeal seeks to settle the matter with the insurance company by providing additional information or asking that the company reconsider its decision. There is a chance that upon further review, the insurance company will alter its decision and offer a settlement.
An external review asks an outside third party to review your claim. An external reviewer will look at your case and either decide in your favor or agree with the insurance company. By law, the insurance company must accept the external reviewer’s decision. Types of claims that are eligible for external review are those involving medical judgments with disagreements over insurance plans, experimental or investigational treatments, or cancellation of coverage based on misrepresentation of information.
Timeline for Internal Appeal vs. External Review
Should you choose the internal appeal route, the maximum amount of time you have to file your appeal is six months (180 days) after receiving a notice from your insurance company that it denied your claim. You can file as quickly after receiving this notice as you like.
Your denial notice will come within 15 days of the insurance company receiving your initial claim for coverage if you need authorization for a treatment, 30 days for medical services you already received, or 72 hours if your case involves urgent care.
To file your internal appeal, you will need to take the time to complete all required insurance forms, get a letter from your doctor or other requested documentation, and perhaps hire a lawyer. The insurance company must complete your internal appeal within 30 days if you haven’t yet received care and 60 days if you have. If the insurance company denies your internal appeal, you then have the right to an external review in many cases.
Filing an external review must come within 60 days of the date your insurance company sent you a final decision. Some plans may give you longer than 60 days. You may undergo a state or federal external review process depending on your situation. The average external review will not take longer than 60 days after receiving your initial request. The reviewer must complete your request as soon as possible.
How to Expedite the Appeals Process
You can request an external review without completing the internal appeals process if your situation is urgent. If waiting would jeopardize your life or health, you can file an expedited appeal. Your insurer must come to a final decision as quickly as your condition requires (at least within four business days of receiving your request).
Other ways to shorten the appeals request is to be as prepared as possible. Gather information, documentation, letters, and evidence your insurance company may ask for as quickly as you can.
Settle easy issues first, such as errors on your forms. If your company still denies your claim, hire an attorney to take care of the appeals process with efficiency. A lawyer can file for an expedited appeal or move the standard appeal along as quickly as possible.