My Health Care Claim Was Denied; Now What? Part 1: Knowing Your Rights

Each year, thousands of Minnesotans are shocked to learn that their health insurance company has denied a claim and will not pay for their medical care.

If you have received notification of a health insurance claim denial, do not panic. Under federal and state laws, you have the right to appeal a denied claim, and several options for having your claim reviewed.

Internal Appeal

You have the right to ask your insurance company to conduct an internal review of the claims decision. During the Internal Appeal process, your insurer must review the claims process, the treatment provided, your medical history and the initial justification for its denial. The review conducted by your insurer must meet specific standards for fairness, objectivity and efficiency.

To request an Internal Appeal, you should gather all documentation related to your claim, complete the necessary paperwork and provide any additional information that supports the initial claim.

It is important to remember that an Internal Appeal request may have a specific deadline by which the appeal must be filed. Under federal law, for instance, appeals must typically be filed within 180 days or six months from the date of the denial notification. The denial letter should tell you when your appeal must be filed.

External Review

If your claim is denied again following the Internal Appeal, you have the right to request a further review by an independent party, known as an External Appeal or an External Review. Under the Affordable Care Act (ACA), insurance companies must participate in an external review process that adheres to the health care law’s consumer protection standards or state specific guidelines.

The External Review process involves a third-party examination of your claim. The reviewer makes a ruling to either uphold the insurance company’s decision or overturn the denial in your favor. Whichever ruling is made, the insurance company is legally bound to adhere to the decision.

External Reviews are most commonly used to appeal denials based on questionable medical opinions, a determination of an experimental treatment or a cancellation of coverage based on the insurance company’s assertion that false or incomplete information was provided to secure the policy.

An External Review request must be filed within a certain time frame and can vary based on your insurance policy. Sometimes as quick as 60 days or as long as four months from notice of the insurance company’s final notice of denial.

You Have Allies

When dealing with the frustration and fear associated with a denied medical claim, the appeals process can seem overwhelming. You don’t have to face the appeals process alone – our health insurance claims attorneys are here to help.

We provide the advice and guidance you need to understand your rights and complete the necessary steps to properly file your appeal. Call (651) 788-0236 or contact our firm online to discuss your claim and learn more about your options for appealing a denial.

Disclaimer: The information in this blog post (“post”) is provided for general informational purposes only, and may not reflect the current law in your jurisdiction. No information contained in this post should be construed as legal advice from Wrobel & Smith, PLLP or the individual author, nor does it create an attorney client relationship. It is not intended to be a substitute for legal counsel on any subject matter. No reader of this post should act or refrain from acting on the basis of any information included in, or accessible through, this Post without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer licensed in the recipient’s state, country or other appropriate licensing jurisdiction

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