. Utilization management sometimes ends in the denial of payment for a service. If you were to have a service denied for payment by your health plan, do you know how you would appeal that decision? Many consumers do not.
So, for this extra credit assignment, please review your health plan member booklet (or find one on the internet). The member booklet should include a section on appeals. Use the appeals section to answer the questions below.
- How do you request an internal appeal?
- How long do you have to request an internal appeal after receiving a denial?
- How does your health plan define “medically urgent” for expedited reviews?
- How long does an appeal decision take?
- How can you request an external appeal?
Full Answer Section
- How does your health plan define “medically urgent” for expedited reviews?
Your health plan will define "medically urgent" based on specific criteria. This may include situations where the denial of services could pose a serious threat to your health or well-being. If you believe your situation qualifies for an expedited review, you should contact your health plan to request one.
- How long does an appeal decision take?
The time it takes to receive a decision on your appeal can vary depending on the complexity of the case and the workload of the health plan. However, your member booklet should provide an estimated timeframe for the appeal process.
- How can you request an external appeal?
If you are dissatisfied with the outcome of your internal appeal, you may be able to request an external appeal. This typically involves filing a complaint with a state or federal appeals board. The member booklet will provide information on how to file an external appeal and the applicable deadlines.
Additional Tips:
- Gather Supporting Documentation: Collect any relevant medical records, doctor's notes, or other evidence to support your appeal.
- Be Persistent: If your appeal is denied, don't give up. You may be able to file multiple appeals or seek assistance from a patient advocate.
- Understand Your Rights: Familiarize yourself with your rights as a healthcare consumer, including your right to appeal denials.
By understanding the appeals process and following the steps outlined in your member booklet, you can increase your chances of successfully resolving a denied claim.
Sample Answer
1. How do you request an internal appeal?
Typically, you can request an internal appeal by submitting a written letter or form to your health plan's customer service department. The member booklet will provide specific instructions on how to file an appeal and what information to include.
2. How long do you have to request an internal appeal after receiving a denial?
The time limit for filing an internal appeal varies depending on the health plan. However, it is generally within a specific timeframe after receiving the denial notice. This information should be clearly stated in your member booklet.