Filing an Insurance Claim Appeal: The Internal Review Process- Part 1

It isn’t at all unusual to find yourself having to file multiple appeals for insurance bills. Especially, with ongoing treatment. Or if you find yourself in the hospital for any period of time, the majority of the subsequent bills you receive may be wrong. In fact, 80% or more of medical bills are incorrect. Therefore, it is very important to properly review and manage them in a timely manner.  In the event, you need to file an appeal you need to have all of your records ready to go.

There are certain denials that can be appealed.  

Such as:

• Services from a provider or facility that isn’t in your plan's network
• The benefit isn't offered under your plan
• Your medical problem began before you joined the plan
• The requested service or treatment service “is not medically necessary”
• Your requested service is an experimental or investigative treatment
• You are no longer eligible to be enrolled in the plan or
• Your coverage is being revoked or canceled going back to the date you enrolled because of false or incomplete information in the application

When your insurance company says no to paying a bill, you have two options. Accept what they say and possibly pay more than you should or submit an appeal. When you are denied payment the insurance company is required to tell you why they’ve denied your claim or ended your coverage. They also have to let you know how you can dispute their decision. You also have a right to have a third party review their decision

There are two ways to appeal a health plan decision: Internal and External. Here we are only going to discuss the internal appeal process.

Internal appeal

This is an appeal with the insurance company in-house. If the case is urgent, your insurance company must speed up this process.

There are 3 steps in the internal appeals process:

1. You file a claim: the claim is a request for coverage. You or your health care provider or a third party will usually file a claim to be reimbursed for the costs of treatment or services provided.
2. Your health plan denies the claim: Again, your insurer must notify you in writing and explain their decision; within 15 days if you're seeking prior authorization for treatment, within 30 days for medical services you’ve already received, and within 72 hours for urgent care cases.
3. You file an internal appeal: In order to file an internal appeal, you will need to complete all appropriate documents and file within 180 days of receiving notice that your claim was denied. Again, if you have an urgent health situation, you can ask for an external review at the same time as your internal appeal. Then, if your insurance provider denies your claim you can file for an external review.

The internal appeal must be completed within 30 days if your appeal is for a service not yet received and in 60 days for a service you have already received. If denied they are required to tell you why, make payment, or you can ask for a second external review.   In the insurance company’s final determination, they must tell you how to ask for an external review.

Make sure you have all of your documents and keep copies of everything you file. Take down the name, date, and time of every person you speak with.  Don’t give up. Stay the course.

If you have questions about how to navigate the financial impact of having myeloma, consider reaching out to a Myeloma Coach. There are many who have experience in financial resources, including Financial Coach Diahanna Vallentine. You can view all Myeloma Coaches and their areas of experience on our website:  www.myelomacoach.org  If you have successfully navigated the financial impact of myeloma treatment and would like to share what you've learned with others- consider becoming a Myeloma Coach.  

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Editor's note: this is part one in a series of articles on this topic.