If your insurer denies your claim, you can request a reconsideration of its decision.[1] Your insurer should provide you with a reconsideration decision within one business day.[2]

If the insurer denies your claim after the reconsideration process, you have the right to a first and possibly a second level grievance review, also referred to as an internal appeal.[3] This means you can ask your insurer to conduct a full and fair review of its decision. To request a first level grievance review, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter telling you 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 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 to file the grievance, 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 grievance process. Someone in his or her office might help you fill out the forms to request a grievance and draft a strong grievance letter.
  • Submit the grievance request. You or someone in your health care provider’s office should submit the grievance 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 review, if applicable. You can request an expedited review of your case if waiting 55 to 110 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function.[4] You can submit your request for expedited review by phone or in writing.[5]
  • 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 grievance, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

Group Health Plans. If you have a group health plan and your insurer denies your claim after the first level grievance review, you can request second level grievance review.[6] Your insurer must notify you of the procedure to request a second level grievance review with its decision on the first level grievance.[7] An advisory panel consisting of members who were not involved in the first level grievance will conduct the second level grievance.[8]

Individual Plans. If you have an individual plan, review your policy to determine whether you are limited to the first level of grievance or if you have the option to request a second level of grievance.[9]