THE APPEALS PROCESS

What Happens When Your Health Insurance Company Says "No"

Adapted from a publication of the Colorado Department of Regulatory Agencies - Colorado Division of Insurance

SELF INSURED PLANS

Under a federal law known as ERISA, state insurance laws do not apply to self-insured health plans. Most large corporations and businesses offer some plans that are self-insured. Some use a health insurance company to handle claims, so you may not know that your health plan is self-insured. To find out, contact your employer's human resources department. All self-insured plans are required to have some type of appeal procedures. The following information applies to State of Colorado health insurance plans only. About 30 percent of Colorado 's group health plans are commercial or State of Colorado plans.

Question: What happens if my health insurance company denied my request to see a specialist or to have a medical procedure?

Answer: You have the right to challenge the decision any time your health plan denies coverage for services that you and/or your doctor feel are medically necessary.

Most health plans have a medical professional that reviews your doctor's or other health care provider's request for care and services to ensure it is a covered benefit and that it is medically necessary and appropriate. This is referred to as "utilization review."

STANDARD AUTHORIZATIONS

Question: What happens if my doctor requests pre-approval for a hospital admission, procedure or service?

Answer: Your health plan has 2 business days after receiving all information from your doctor to make a decision to approve or deny the request. The plan must notify your doctor of the decision to approve or deny your request within 1 working day by phone, and notify you by fax or in writing.

Question: What happens if the plan denies my doctor's request?

Answer: The plan must write, fax or e-mail you within 1 working day after making the decision. The notice of denial must include the main reasons for the refusal to pay for the treatment, how to initiate an appeal, and how to request a written statement of the clinical criteria used in the decision.

Your doctor has the right to talk to the plan doctor involved in the denial. Your doctor may ask for reconsideration of the decision, either orally or in writing. The health plan must make a decision within 1 working day after receiving the new request.

Question: What happens if I submit a claim for care or services already received?

Answer: Your health plan has 30 days after receiving all information to review the service and determine whether or not it was medically necessary. If the claim is denied, the plan has 5 working days after making its decision to tell you and your doctor in writing. The letter must include:

The reason for denial.
How to appeal the decision.
How to request a written statement giving the medical reason for the denial.

Question: What happens if I believe I have been inappropriately denied a benefit?

Answer: The appeals process is followed.

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