Third-Party Payer Denials

Although third-party payers may have specific instructions on how claims are appealed, certain provisions are mandated by the Federal Government and outlines on the Healthcare.gov website at this link: https://www.healthcare.gov/appeal-insurance-company-decision/appeals/

There are two ways to appeal a health plan decision:

Internal appeal: If a claim is denied, the insured has the right to an internal appeal. They may ask the insurance company to conduct a full and fair review of its decision. If the case is urgent, the insurance company must speed up this process. An internal appeal must be filed within 180 days (6 months) of receiving notice that the claim was denied.

External review: The insured also has the right to take their appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim. The written request for an external review must be filed within four months after the date the insured receives a notice or final determination from the insurer that the claim has been denied.

A CMS CCIIO Fact Sheet on Appealing Denials is here: https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/IndexAppealingDenials