Your health plan will review your coverage for a treatment, service, or prescription either before or after your claim is filed. If your health plan refuses to pay for medically necessary services, treatments, or medications, you have the right to appeal the decision through the plan’s internal appeal process. You must consult your plan documents or contact your plan or employer for details on your plan’s appeal process.
Typically a plan will require you to complete forms or write a letter indicating that you are appealing the decision. You may submit any additional information that you want the insurer to consider. The letter you submit for your appeal does not need to be technical, but you should specify what claim denial you are appealing and why you believe the company should review the denial. Typically you must file your appeal within 180 days (six months) of receiving notice that your claim was denied. Make sure you keep copies of all information related to your claim and the plan’s denial, including information the plan provides to you. This includes Explanation of Benefits (EOB) forms, a copy of any information you send to the company, and notes from any phone conversation you have with your insurer about the appeal.
When you have exhausted your internal appeal rights, you may have the right to have the decision reviewed externally by an independent review organization (IRO). Your health plan must provide an independent review form if it denies payment based on a decision that the treatment is unnecessary, inappropriate, experimental, or investigational. Your health plan must pay for the review and must comply with the IRO’s decision.
The IRO must issue a decision within twenty days for non-emergency treatment and within five days for emergency treatment. The law does not require a plan to provide an IRO for services it does not cover. It also does not require certain types of plans—Medicare, Medicaid, and ERISA plans, for example—to participate in the IRO process.
For more information on IROs, contact TDI’s Health and Workers’ Compensation Network Certification and Quality Assurance Office at 1-866-554-4926 or visit its website at https://www.tdi.state.tx.us/wc/wcnet/
Steps to appeal a health care claim denial:
1. Review your plan documents or contact your plan or employer for details on how to appeal the denial.
2. Submit your appeal within 180 days of receiving notice that your claim was denied.
3. Keep copies of all information related to your claim and the plan’s denial.
4. If the company still denies your claim, request an external review (IRO) of the denial.