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| HEALTH PLAN REVIEW Once the plan receives your written appeal, it will investigate the appeal and make a determination setting out what the plan is willing to do. This procedure goes by different names at different health plans; it may be called an internal review, a level I appeal, or a desk review. The key feature is that this is the first step in the formal plan appeal process. At this level of review, you may or may not have further contact with the health plan. Some plans allow for informal discussions or consultations between the person making the appeal and the person who is reviewing it. Other health plans will review the documentation for your case and notify you only after making a decision. Note that federal ERISA regulations applicable to employer-sponsored health plans (both insured and self-funded) provide consumers with the right to present written comments, documents, records, and other evidence to the health plan for consideration in the appeal process. Response times vary from plan to plan depending on the type of dispute. The plan will usually act more quickly if the service has not yet been provided, or if the patient is already in the hospital. Some health plans say that they handle the first level of reviews within one business day for services not yet provided, but other plans may take longer. The federal ERISA regulations applicable to employer-sponsored health plans set maximum response times for different types of appeals: 30 days if the service has not yet been provided, or 60 days if it has been provided. State law also may establish response times for appeals to individually purchased health plans. Health plans may have expedited processes to deal with requests for medical services that your doctor feels are urgent. If your appeal involves an urgent need for care, make that clear to the health plan so it can expedite your appeal. Federal ERISA regulations require employer-sponsored health plans to respond to an urgent care claim within 72 hours. If you do not agree with the results of the plan’s initial review, most plans allow you to appeal the decision to a panel of individuals who were not involved in the initial decision. In some cases you will be asked to appear at a hearing to discuss your case; in others you will not. Each health plan has its own rules about who will be members of the review panel. It may include physicians, consumers, or sometimes representatives of the health plan. Federal ERISA regulations applicable to employer-sponsored health plans require that if the appeal involves a medical judgment, the reviewers must consult with a qualified health care professional. If your plan is subject to state external review requirements, it will usually notify you that it has denied your appeal and tell you how to file for an external appeal. Here is a checklist to help you keep track of your appeal. Keep this information handy, and update it if you change your health plan. WHO TO CONTACT REGARDING A HEALTH PLAN APPEAL Who to call: _____________________________________________ Where to write: _______________________________________ _______________________________________ _______________________________________ How soon must I appeal? ___________________________________ How many days will it take to receive a response? (List the response times for each level of review) 1st level ____________________________________________ 2nd level ____________________________________________ Expedited appeals (for medical emergencies) ____________________ Note: Federal ERISA regulations for employer-sponsored health plans provide that a health plan can’t require more than two levels of appeals, and that if two levels are used, both must be completed within the response time allowed by the regulations. |
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