The appeals process begins after your insurance company gives you an "adverse determination" letter. This letter must come within three days of the initial utilization review and must include the reasons your request was denied, information on how this denial can be appealed and information on how to obtain the company's clinical review criteria. Once you've received this letter, you have the option to file an appeal.
The first step may be obvious -- call your insurance company to say you want to file an appeal. If you leave a message with this information, the insurance company is required to return your call within one business day. At this point you can choose an expedited or standard review of the appeal. Normally, you'd want an expedited review when the denied medical coverage is needed immediately. Pick the standard review if you don't need the coverage immediately or if an expedited review is denied.
Once the appeal begins, you or your provider may have to provide the insurance company with additional medical information. This information should be reviewed by the insurance company or outsourced to a utilization review organization. Licensed and registered utilization review agents (usually physicians or other health care providers) who know about your particular condition must make this decision.
After you've handed over all the requested information, the insurance company must respond to your appeal within a set time frame. For expedited appeals, you should receive a decision within two business days. With a standard appeal, the decision should be issued within 60 days. These time frames can prove extremely important -- if your plan does not respond within the set time line, the initial denial of coverage is automatically reversed and your insurance company must pay for the services. So be sure to keep track of what you sent and when you sent it.
If your appeal is denied, your insurance company is required to send you a "final adverse determination" letter. This document should include the specific reasons for the denial, along with any necessary medical explanations. It should also provide information on how you can receive a copy of the insurance company's clinical review criteria. Finally, depending on your state's laws, the letter may include information on how to make an external appeal that involves a third-party decision-maker, usually an independent review organization.
For more information about utilization reviews, take a look at the links on the next page.