Group plans. If you have a group health plan, you must first file a formal complaint with your health insurer before requesting an internal appeal.[1] Your complaint may be submitted orally (by phone) or in writing directly to your health insurer.[2] Your member handbook, contract, or certification of coverage must include clear directions on how to submit a complaint. You should follow those instructions.[3] The complaint process may take up to 44 days to complete.[4]

If your group health insurer denies your claim after submission of your complaint, you have the right to an internal appeal.[5] This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
  • Collect information. In addition to the determination letter, collect all of the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
  • Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
  • Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
  • Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
  • Request an expedited appeal, if applicable. You can request an expedited appeal if your health care provider believes that your situation is urgent. In such case, ask your health care provider to call your insurer and ask for the expedited appeal.[6]
  • Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

Individual plans. If you have an individual health plan, you must file a formal complaint with your health insurer either orally (by phone) or in writing.[7] Your member handbook, contract, or certification of coverage must include clear directions on how to submit a complaint, and you should follow those instructions for submitting your complaint.[8] The complaint process may take up to 44 days to complete.[9] If your complaint is denied, check to see if your insurer follows the internal appeals process.[10] If it does, follow the instructions above for submitting internal appeals. Otherwise, when you receive notice of the denial of your complaint, your health insurer will include instructions regarding how to submit your claim to external review.[11]