QUESTION

I was denied coverage for a service my doctor said I need. How can I appeal the decision?

Post enrollment issues | Individual Health Insurance
ANSWER

If your plan denied you coverage for a service your doctor said you need, you can appeal the decision and ask the plan to reconsider their denial. This is known as an internal appeal. If the plan still denies you coverage for the service and it is not a grandfathered plan, you can take your appeal to an independent third party to review the plan’s decision. This is known as an external review.

You will have 6 months from the time you received notice that your claim was denied to file an internal appeal. The Explanation of Benefits you get from your plan must provide you with information on how to file an internal appeal and request an external review. Your state may have a program specifically to help with appeals. Ask your Department of Insurance if there is one in your state.

For more information about the appeals process, including how quickly you can expect a decision from your plan when you file an internal appeal, click here. (45 C.F.R. § 147.136).

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