Medical issues are often one of the most stressful things that the average person must deal with. For many, there is stress in simply scheduling and going to appointments. For others, the stress comes from having to navigate the complexities of the insurance system. This becomes even more stressful when you have a claim denied and you must appeal. For some, it may seem easier to forego the appeal. This should not be the solution. There are varying levels of appeals and it can be helpful to learn about them before you give up on appealing your denial. Let’s dive in for a quick overview.
An internal appeal is the first stage of the appeal process. After a claim is denied, you or your healthcare provider will submit a request for consideration. This is called an internal review because it is all done inside the insurance company. While the request is initiated externally, there are no external agents or inspectors involved in the review process. Occasionally, your doctor may request something called a peer-to-peer review – this is when your provider and the medical reviewer working for the insurance company have a one-on-one phone conversation where they discuss the charge and the medical necessity. After the appeal, the insurance company has 30 days (for pre-authorizations) or 60 days (for already performed services) to respond to it. If you request an expedited appeal, the company only has 72 hours to decide. In some cases, this is the only internal appeal you will do. In other cases, there can be additional levels of internal review. Often the second-level internal review will be done by an internal medical reviewer who has not yet worked on your case. In many cases, you must go through all the levels of internal review before you can request an external review.
Once you have completed the entire internal review process, you can progress to an external review. This is when you contact your state’s bureau of insurance and request that your situation be reviewed. The final denial letter that you receive in the internal review process will have instructions for how to request an external review. Once you request the review, the bureau will notify the carrier, and the insurance carrier can request additional information that you have to provide to them. If you don’t provide the information in the time frame they state, your request will be denied. If your request is deemed eligible for external review, this will be done by an impartial third party chosen by the bureau of insurance. Requests for external review that are denied can also be appealed.
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