There are 3 steps in the internal appeals process for health insurance claims:
- You file a claim: A claim is a request for coverage. You or a health care provider will usually file a claim to be reimbursed for the costs of treatment or services.
- Your health plan denies the claim: Your insurer must notify you in writing and explain why:
- Within 15 days if you’re seeking prior authorization for a treatment
- Within 30 days for medical services already received
- Within 72 hours for urgent care cases
- You file an internal appeal: To file an internal appeal, you need to:
- Complete all forms required by your health insurer. Or you can write to your insurer with your name, claim number, and health insurance ID number.
- Submit any additional information that you want the insurer to consider, such as a letter from the doctor.
- The Consumer Assistance Program in your state can file an appeal for you.
You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal.
If your insurance company still denies your claim, you can file for an external review.
How long does an internal appeal take?
- Your internal appeal must be completed within 30 days if your appeal is for a service you haven’t received yet.
- Your internal appeals must be completed within 60 days if your appeal is for a service you’ve already received.
- At the end of the internal appeals process, your insurance company must provide you with a written decision. If your insurance company still denies you the service or payment for a service, you can ask for an external review. The insurance company’s final determination must tell you how to ask for an external review.
Here is a Sample Health Insurance Claim Form
