If you have a group health plan and your insurer denies your claim, you have the right to two levels of internal review (sometimes referred to as an internal appeal).[1] This means you can ask your insurer to conduct a full and fair review of its decision.

First level internal review. To request the first level review, 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 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 internal review, if applicable. You can request an expedited internal review if one of the following applies:

  • Waiting 30 to 60 days for your requested treatment would jeopardize your life, health, or ability to regain function;
  • Your health care provider requests an expedited decision from your health insurer;[2]
  • Your medical condition would result in severe pain that cannot be adequately managed without the requested treatment or service; or
  • You are experiencing a medical emergency.[3]

If you believe you qualify for an expedited internal review, contact your insurer immediately and ask for instructions on how to request one.[4]

  • 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.

Second level internal review. Your health plan should also offer a second level internal review.[5] This process is optional. Your insurer will contact you after denying your claim in the first level internal review to provide you instructions on the second level internal review.[6]

If you choose to request a second level internal review, the health insurer will select an internal review panel to review the insurer’s decision.[7] You have the right to attend the panel review hearing, present your case to the panel, submit any additional supporting information or documentation, ask questions of health care professionals on the panel, and be assisted or represented by a person of your choosing.[8] If your case is under expedited internal review and your health insurer is unable to contact you to ask if you want a second level internal review, the insurer will automatically convene a second level review panel.[9]