SECTION 2
APPEALING TO YOUR HEALTH PLAN

Disputes with health plans arise over whether services are covered, which treatments should be provided, which providers should be used, how much a service should cost, difficulties dealing with providers, and even billing and administrative mistakes.  In most cases, your health plan will have an established appeals process to handle these disagreements.  For employer-sponsored health plans (both insured and self-funded), federal ERISA regulations establish procedures and timelines for disputes involving claims for benefits (i.e., whether a service is covered and how much it should cost).  Also, states have their own rules about how health plans must conduct their internal appeals. Even if you are eligible to use your state’s external review procedure, you will usually have to complete your health plan’s internal appeal process first, so it is important to learn how that process works.

Health plans can have different appeals processes for different types of disputes.  For example, a health plan may have a different process for resolving a complaint about appointment times than for an appeal involving a denial of a benefit or a refusal to authorize a medical procedure.  Federal ERISA regulations set up other requirements for employer-sponsored health plan appeals, such as requiring health plans to let you see the documents used to determine whether or not you have coverage for the services in dispute, allowing no more than two levels of review, and prohibiting a fee for the review.