MADISON, Wis. (8/4/10)--Patients have gained new rights to appeal the denial of health insurance claims. According to rule changes resulting from passage of the Affordable Care Act (U.S. Dept. of Health and Human Services
July 22), consumers covered by health plans that go into effect beginning Sept. 23 must have access to standardized internal appeals as well as to an independent third-party review of claim denials. Before, because of state-by-state inconsistencies, you might not have had recourse if your health insurer refused to cover recommended treatments or pay certain medical bills. External appeals have a history of effectiveness--a 2002 Kaiser Family Foundation study found that, in states with such a process, consumers won against their insurance companies 45% of the time
. Under the new regulations, you have these assurances:
* Internal appeal. Your health plan must give you detailed information about the grounds for denial of claims or coverage. It must inform you of your right to appeal a negative decision and tell you how go about it. It must provide a review that is complete and unbiased. * External appeal. Your health plan documents must include clear information about your right to a uniform external appeals process that meets National Association of Insurance Commissioners’ standards. When your insurer denies a claim, it also must inform you of your right to appeal to an independent reviewer who is not a health plan employee or who has no other conflict of interest. You must not be charged more than a nominal fee for the external review, whose decision is binding--if you win, your insurer must pay for the previously denied benefit.
In emergencies, you have the right to institute an external appeal without waiting for an internal review to run its course. Furthermore, insurers must expedite both processes for speedy resolution of disputed claims regarding urgent cases.