August 2005

Most people get their health care through some form of managed care plan - a health maintenance organization, preferred provider organization, or point-of-service option. Most of the time, people receive the care they need, but the potential exists for disagreements over the services that will be provided or paid for by health plans.

Health plans are required to follow state and federal rules for handling their enrollee's complaints and appeals inside the health plan, known as an "internal review." Many states have legislated additional procedures outside of the health plan, called "external reviews" or "independent reviews," to provide an unbiased way to resolve disputes between patients and their health plans. An external review is a reconsideration of a health plan's denial of service, with the review conducted by a person or panel of individuals who are not part of the plan. As of December 2004, 43 states plus the District of Columbia had legislated such procedures.

Anyone enrolled in a health plan should be familiar with their plan's internal review process and any external review program in their state in case problems later arise. This guide will help you navigate your employer or private health plan's internal grievance procedure, as well as any external review program your state may have. The guide is not applicable, however, for resolving disputes if you have Medicare or Medicaid coverage.

Click on a state for details about your state's external review program, or see text list of states.

Report Contents

Introduction

Section 1 -- Know Your Coverage

• Understand What Type of Coverage You Have & What Laws Apply
• Understand What Services Are Covered
• Understand Your Plan's Rules
• Checklist For Diagnosing Your Coverage

Section 2 -- Appealing To Your Health Plan

• Preparing an Informal Appeal
• Preparing a Formal Appeal
• Health Plan Review
• Arbitration

Section 3 -- Getting An Independent Opinion -- External Review in Your State

• Who Can Appeal
• What Types of Problems You Can Appeal
• When You Can Appeal
• How To Appeal

Section 4 -- How Consumers Fared Under External Review Programs

• Mistakes That Make External Appeals Ineligible
• External Appeals Outcomes

Section 5 -- State-By-State External Review Programs

• Full Report