Filing an Insurance Claim Appeal: The External Review Process, Part 2

Editors Note: This is part two of a series of articles on this topic. This information is a follow up to the article, Filing an Insurance Claim Appeal: The Internal Review Process-Part 1

We last discussed the process of filing an internal appeal for an insurance Claim. Next, we are going to focus on filing an external appeal for an insurance claim that has been denied.

You always have the right to take your appeal to an independent third party for review. This third-party reviewer can uphold the internal review decision or can overturn the plan’s decision. This independent reviewer is not related to the plan. Additionally, their decision is final.

Types of denials that can go through an external review:

• Any denials that involve medical judgment where you or your provider may disagree with the health insurance plan
• Any denial that involves a determination that a treatment is experimental or investigational
• Cancellation of coverage based on your insurance claim and you gave false or incomplete information when you applied for coverage.

There are 2 steps in an External Review Process:

1. You file an external review: You must file a written request for an external review within four months after the date you receive a notice or final determination from your insurer that your claim has been denied.

2. External reviewer issues a final decision: An external review either upholds your insurer’s decision or decides in your favor. Your insurer is required by law to accept the external reviewer’s decision.

It is important for you to know that all insurance companies must offer an external review process that meets the federal consumer protection standards. You can find those standards here.

Your rights in the external review process:

• State: Your state may also have an external review process that meets or goes beyond the federal standards. If so, insurance companies in your state will follow your state’s review processes. And, you will get all protections outlined in that process
• Federal: If your state doesn’t have an external review process that meets the minimum consumer protection standards, the federal government’s Department of Health and Human Services (HHS) will oversee an external review process for health insurance companies in your state.

If the federal government oversees the process, insurance companies may choose to participate in an administered process or contract with independent review organizations

If your plan does not participate in a state Administered Federal External Review Process, your health plan must contract with an independent review organization.

You can find out more about your state’s external review by reviewing information on your Explanation of Benefits (EOB) or on the final denial of the internal appeal by your health plan.

Standard external reviews are decided as soon as possible or no later than 45 days after the request was received. Expedited external request reviews are decided as soon as possible, or no later than 72 hours or less, depending on the medical urgency of the case, after the request was received.

To request an external appeal through the Health and Human Services-Administered Federal External Review Process through a secure website visit: externalappeal.cms.gov. Or call 888-866-6190.

If you are unable to file yourself, you can appoint a representative such as your doctor or another medical professional who is aware of your medical condition to file on your behalf. The authorized representative form is available at: externalappeal.cms.gov.

The cost associated with the external appeal process is $0.00 if using an HHS process. However, if your insurance company has contracted with an independent review organization or is using a state external review process, you may be charged a fee that cannot be more than the $25 per external review.

Where to go, if you need help filing an external appeal:

1. Your states Consumer Assistance Program (CAP) or Department of Insurance

2. CoPatient

3. Triage Cancer in partnership with CoPatient

Don’t let denied medical bills overwhelm you and don’t assume that you have to pay them. Because many medical bills especially inpatient bills are incorrect you should not pay for these mistakes. Solicit help if you can’t manage this on your own.

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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