A health insurance denial isn’t necessarily final. When an insurer refuses coverage for a needed surgery or other medical care, the patient may have the right to challenge the denial through an internal appeal, an external review or both.
Internal appeals and external reviews have similar purposes, but they’re handled by different parties.
How is an internal appeal handled?
The denial notice should explain how to file an appeal and offer a deadline. For many health plans, patients have up to 180 days after receiving the denial to request an internal appeal. However, deadlines and procedures can differ.
An internal appeal gives the insurer a chance to review its decision and reconsider the original denial. Someone who wasn’t involved in the initial decision should review the claim, the policy terms and any additional information the patient or medical provider submitted, such as:
- Medical records and test results
- A letter from the treating physician
- Evidence that other treatments were ineffective
- Medical research supporting the requested treatment
- The insurer’s denial notice
- Relevant language from the insurance policy
If the insurer still denies coverage for the medical services after its internal review, the claim may be eligible for an external review.
What happens during an external review?
An external review sends the dispute to an independent third party that is not connected to the insurance company. The independent reviewer examines the medical evidence, the insurer’s reasoning and the terms of the health plan. If the reviewer overturns the denial, the insurer generally must follow that decision and cover the medical procedure.
Not every dispute qualifies for external review. It’s commonly available for denials that involve claims of medical necessity, level of care, effectiveness of treatment, experimental treatments and questions about appropriateness of care. Denial notices should explain whether external reviews are available and how to initiate one.
Insurance appeals can involve short deadlines and complicated plan language. If an insurer refuses to reverse an unsupported denial or fails to provide access to an external review, an attorney can help affected patients understand their rights and pursue the coverage they need.