How Long Does a Health Insurance Appeal Take?

If you’re denied a health insurance claim, you should understand the process for appealing your decision. Insurance companies have specific timetables and policies that may impact how long it takes to make a decision on your appeal. Understanding these rules can help you get the most out of your coverage. There are two main ways to appeal: external review and internal review. Depending on the situation, you may be able to use both of these methods.

An external review is when you go to a third party to review your insurance company’s denial. Typically, an independent review organization will evaluate your medical records and make a final, binding decision. You will then receive a written notice of the decision. Usually, this decision is based on state laws. However, some states have exceptions to the external review rule.

In addition to the standard appeal, you can also request an expedited internal review. This is a more rapid process than the standard, but it can still take up to three days. Expedited reviews are often used when the time between the initial denial and the insurance company’s decision is short and could jeopardize your life or health.

Most health plans will have at least two levels of internal review. One level is usually the standard appeal. The other is a second-level internal appeal, which is made by a medical reviewer working for the carrier.

For the standard appeal, the insurance company must provide a decision within 30 days. However, the company can take more than 60 days if it needs to do further review of your case. Also, you can submit your appeal electronically, by fax or in person.

If you need urgent care, you can request an external review. Depending on the situation, you can request this as soon as you are given a denial letter, or even before you have been told that you are not eligible for the treatment you need. Often, you will need to provide documentation that shows that the treatment is medically necessary. After the doctor and the insurance company have discussed your claim, you should be able to find out if you can receive the treatment you need.

Another way to appeal an insurance decision is by going through a consumer assistance program. These programs have consumer advocates who can help you file your claim. Alternatively, you can contact your state insurance regulator for more information. Before making an appeal, you should be sure to read your health plan and its summary of benefits to determine if your insurance provider offers a consumer assistance program.

When requesting a health insurance appeal, you should be concise and respectful. Make sure you know what your rights are, and never threaten the insurer with a lawsuit. Keep accurate records of your calls and your appeal. Your insurer will want to review the information you provide and will be unable to accept anything that does not match the documentation you provide.