The Pennsylvania Insurance Department’s

Your Guide to filing

HEALTH INSURANCE

APPEALS
Sometimes a health plan will make a decision that you disagree with. The plan may deny
your application for coverage, determine that the healthcare services you requested are
not covered or only partially covered or cancel your policy back to the date it started.

If you disagree with the health plan’s decision, the first thing to do is contact your health
plan and your health provider to see if you can resolve the situation. If you continue to
disagree, you may have the right to file an appeal.

The Affordable Care Act (ACA), the federal healthcare reform law passed in March
2010, provides consumers with several appeal rights. These rights apply to “non-
grandfathered,” fully-insured plans and self-funded plans.

Health plans must tell you if your plan is “grandfathered.” These plans generally
do not have to follow ACA appeal guidelines with some exceptions. Contact the
health plan for this information.

This guide provides information on how consumers can file a health insurance appeal
if they are covered by a non-grandfathered plan.

Learn more at PAHealthOptions.com

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What is an appeal?

An appeal is when you ask a health plan to reconsider its decision to deny payment
for a service or treatment. There are generally three types of appeals:

1.INTERNAL APPEAL: The health plan reviews the situation internally. You can
file an internal appeal for just about anything. Your plan may offer several levels of
internal appeal. If the health plan:

• DENIES A PRIOR AUTHORIZATION for services (a request made

by you or your healthcare provider to the health plan to approve a specific
treatment or service before it is delivered – commonly called a “Pre-Cert,” short
for pre-certification), it will make a verbal denial to the medical provider and
follow-up with a letter to you and the provider.
• DENIES A POST-SERVICE CLAIM (a claim submitted by you or your health
provider after receiving treatment or service) in whole or in part, you will be
informed of the denial on your Explanation of Benefits (commonly called an EOB).

You must exhaust all of the internal appeals available to you before
moving to an external review.

2.EXTERNAL REVIEW: An independent third-party expert reviews the situation.

External reviews are available only for rescission of coverage and coverage decisions
involving issues of:

• healthcare setting • effectiveness of a covered benefit

• level of care • experimental/investigative treatment
• effectiveness of a covered benefit • other matters involving medical judgment
• experimental/investigative treatment (also called Adverse Benefit Determinations)
• healthcare setting, level of care

External reviews are generally not available for contractual issues such as excluded
benefits, limitations and other contract conditions.

3.EXPEDITED REVIEW: In an urgent care situation, the internal appeal and

external review can be handled together if the case is subject to external review.

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 The Pennsylvania Insurance Department’s

What if my application for

health insurance is rejected?

Appeals regarding rejections of health insurance applications are not covered

under ACA. However, you can take steps to better understand or refute the
health plan’s decision or reapply for coverage.

When you apply for health insurance, the plan uses a process called medical underwriting
to determine whether or not to offer you coverage and how much to charge you for
coverage. Medical underwriting includes a thorough review of your medical history.

If your application is rejected:

• Carefully review the rejection letter.

• Contact your physician to see if they can provide any
documentation on your behalf.
• Follow the appeal process, if any, outlined in the rejection letter.

If you choose to correspond with the health plan regarding denial of the application,
a sample letter is included at the end of this guide. Keep copies of all correspondence
in a safe place.

Learn more at PAHealthOptions.com

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 The Pennsylvania Insurance Department’s
The internal appeal process
1. Y
 ou or your healthcare provider request a
pre-authorization or file a claim to be
reimbursed for the cost of treatment or service.
2. If the plan denies the pre-authorization or claim
in whole or in part, or rescinds coverage back to
the issue date of the policy, it must notify you –
in writing – of the denial and explain why the
claimwas denied. It must do this within:
• 15 days for prior authorization
• 30 days for medical services already received
• 72 hours for urgent care cases
The denial notice must explain:
• The reason for the denial
• Your right to appeal the health plan’s decision
• How to file an internal appeal
• Your right to file an external review, if necessary
• The contact information for the Pennsylvania
Insurance Department, Bureau of Consumer
Services
• Availability of linguistic services within
certain communities
If you live in a county where at least 10 percent
of the population speaks the same non-English
language, the appeals notice must tell you how
you can get the notices translated and what
customer help is available in that language.
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3. If you receive a denial notice, check your
member handbook to be sure you understand
your coverage. Contact your health plan and
healthcare provider to see if you can resolve the
claim without going through the appeals process.
If you are not satisfied, you may begin the formal
appeals process.
4. Y
 ou may file an internal appeal, in which you
ask the plan to review its decision to deny your
claim or rescind your policy. You must submit
your written request for internal appeal to your
company at the address it provides. Submit any
additional information, such as a letter from
your healthcare provider, which the plan should
consider.
You must file your appeal in writing within
180 days of receiving notice that your claim
was denied.
5. The plan makes its decision – either to stand
by its original decision to deny the claim or to
provide benefits for the claim. The plan must
make its decision within:
• 30 days for prior authorization or rescission
• 60 days for medical services already received
• 72 hours (or less) in urgent care cases
6. The plan may have a second level of internal
appeal that you will need to follow before the
internal process is complete.
 The Pennsylvania Insurance Department’s

HOW TO REQUEST AN EXTERNAL REVIEW

You may request an external review if the health plan upholds its internal decision and that
decision involves an Adverse Benefit Determination (ABD) as defined by the ACA. The external review will
be conducted by an independent expert who does not work for or who is not related to the health plan. If
the external reviewer overturns your plan’s denial decision, the plan must make the payments or
services you requested.

The health plan will advise you of the levels of appeals available to you. Generally, all issues can be
appealed internally but only ABDs are eligible for external review. In Pennsylvania, plans may choose to
handle external reviews in one of two ways: The health plan has either contracted with an independent
third-party review organization (IRO) or has opted to have an entity under contract with the federal
government conduct the external review. Health plans had to report by January 2012 which external
review process they were going to use. Your plan is required to advise you of next steps within the final
internal appeal determination.

The internal appeal decision will tell you how long you have to file for an external review. Under some
plans, it may be as little as 60 days.

HOW TO FILE FOR EXPEDITED REVIEW WHAT ARE MY RIGHTS IF I WANT TO

If you have an urgent healthcare situation, you may
ask your health plan to expedite the appeal process. In
an urgent care situation, the internal appeal and external
review may be handled together (if the case is an
ABD subject to external review). You are able to file an
expedited appeal in one of these two situations:
• You are currently receiving, or were prescribed to
receive, treatment and have an urgent situation.
An urgent situation is when a medical provider
believes a delay in treatment could jeopardize your
life or health, affect your ability to regain maximum
function or subject you to intolerable pain.
• You have an issue related to admission, availability
of care, continued stay or emergency services and
have not been discharged.
You or your authorized representative may verbally
request an expedited appeal from the health plan. The
health plan must respond as soon as possible but no
longer than 72 hours after your request. It may respond
verbally, but must follow-up with a written decision.
APPEAL A HEALTH PLAN DECISION?
• You have the right to know why a claim
has been denied.
• You have the right to see what the health plan
relied on in making its denial decision.
• You have the right to appeal the plan’s decision and
have the company review its decision.
• If the health plan upholds its original decision
during the internal appeal process, you have the
right to an independent third party review – in
cases of Adverse Benefit Determinations
(including rescission). Both you and the plan have
to abide by the third party’s decision.
It is your right to ask for an appeal. Your plan cannot
drop your coverage or raise your rates because you ask
them to reconsider a denial.

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Need help?

If you need help filing an internal appeal or THINGS TO REMEMBER

an external review request, please contact the
Pennsylvania Insurance Department.
PENNSYLVANIA
INSURANCE DEPARTMENT
Bureau of Consumer Services
1209 Strawberry Square
Harrisburg, PA 17111
877-881-6388
PAHealthOptions.com
Pennsylvania participates in the federal
external review process. This means that your
health insurance company uses either a
process administered by the federal
Department of Health and Human Services
(HHS) or an independent process. If it uses the
HHS process, you may call 1-877-549-8152 to
request an external review request form.
Once you have completed the external review
request form, you may submit your request in
one of three ways:
• Complete all forms accurately and honestly.
• Keep copies of all paperwork or e-mail
correspondence pertaining to a claim.
• rite down the names and contact
W
information for everyone you speak to or
e-mail regarding the claim.
• eep a timeline of events, starting with
K
the date of service or when the claim was
initially denied. Include details about all
conversations or e-mails you have about
your claim.
• ay close attention to required timeframes
P
to be sure both you and the health plan are
responding according to the timeframes
given in the law.

• E-mail: disputedclaim@opm.gov
• Fax: 202 - 606-0036
• Mail: P.O. Box 791, Washington, D.C. 20044

Alternatively, you may be able to file your

request online at www.externalappeal.com.

If your health plan does not participate in

the HHS external review process, or if your
health plan is self-insured, contact your
health plan for information on how to file
for an external review.

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 The Pennsylvania Insurance Department’s

GLOSSARY
-A- -I-

ADVERSE BENEFIT DETERMINATION (ABD) INDEPENDENT REVIEW

A plan’s decision to deny a claim in whole or in part
based on medical judgment or rescission.
AFFORDABLE CARE ACT (ACA) (also known as
the Patient Protection and Affordable Care Act) – is the
federal healthcare reform legislation signed by President
Obama in March 2010.
-C-
CPT CODE Current Procedural Terminology (CPT)
codes are numbers assigned to a medical, surgical or
diagnostic service, from a healthcare provider.
-E-
EXPLANATION OF BENEFITS (EOB)
A document sent by your insurance company that gives
you information about how an insurance claim from a
healthcare provider was paid on your behalf.
EXTERNAL REVIEW An outside review by an
independent third party of a health plan’s Adverse
Benefit Determination.
-G-
GRANDFATHERED PLAN A health plan in
which an individual was enrolled prior to March 23,
2010, and that has not significantly changed its benefits
or cost-sharing requirements. Grandfathered plans are
exempted from most changes required by ACA. New
employees and family members may be added to group
plans that are grandfathered.
ORGANIZATION (IRO) An independent
third-party organization contracted to conduct an
external review of health appeals.
INTERNAL APPEAL A review of a health plan’s
determination that a requested or provided healthcare
service or treatment is not or was not medically
necessary. All plans are required to conduct an internal
review upon the request of the patient or the patient’s
representative.
-M-
MEDICAL JUDGMENT A healthcare provider’s
judgment, based on observation, knowledge and
experience, leading to a diagnosis or treatment
decision for a patient.
MEDICALLY NECESSARY Generally speaking,
services or supplies needed for diagnosis or treatment
that meets accepted standards of medical practice. Your
health plan may have a more specific definition.
MEDICAL UNDERWRITING The process a
health plan uses to determine your health risk when you
are applying for health insurance. Companies use this to
decide whether or not to offer you coverage, how much
to charge you for coverage and if there will be exclusions
or limits.

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-N- -U-

NETWORK ADEQUACY For plans that use
networks, the term for evaluating whether a plan
has an adequate number of healthcare providers
in its provider network to allow members to access
covered healthcare services without unnecessary
barriers.
URGENT CARE CLAIM A claim you may
make for expedited review of your denied claim.
You may make this claim if a medical provider
believes a delay in treatment could jeopardize your
life or health, affect your ability to regain maximum
function or subject you to intolerable pain.

NON-GRANDFATHERED PLANS Health

plans that started after the ACA was signed into law
or plans that existed before the law was signed that
have made significant changes that have reduced
benefits and/or raised costs.

-P-

PRE-EXISTING CONDITION A physical

or mental condition including a disability for
which a patient receives diagnosis or care.

-R-

RESCISSION The retroactive cancellation

of a health insurance policy. Rescission is
prohibited except in cases of fraud or intentional
misrepresentation of a relevant fact.

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 The Pennsylvania Insurance Department’s

Sample letter to request

an internal appeal

Your Name
Your Address

Date

Address of the Health Plan’s Appeal Department

Re: Name of Insured

Plan ID#:
Claim #:

To Whom It May Concern:

I am writing to request a review of your denial of the claim for treatment or

services provided by name of provider on date provided.

The reason for denial was listed as (reason listed for denial), but I have reviewed
my policy and believe treatment or service should be covered.

 ere is where you may provide more detailed information about the situation.
H
Write short, factual statements. Do not include emotional wording.

If you are including documents, include a list of what you are sending here.

If you need additional information, I can be reached at telephone number

and/or e-mail address.

I look forward to receiving your response as soon as possible.

Sincerely,

Signature

Typed Name

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 The Pennsylvania Insurance Department’s

Sample letter to request an internal appeal

(rescission)

Your Name
Your Address

Date

Address of the Health Plan’s Appeal Department

Re: Name of Insured

Plan ID#:
Claim #:

To Whom It May Concern:

I am writing to request a review of your rescission of my policy with the effective

date of effective date.

The reason for rescission was listed as (reason listed for rescission), but I have reviewed
my initial application and believe the information provided was accurate.

Here is where you may provide more detailed information about the situation. Write
short, factual statements. Do not include emotional wording.

If you are including documents, include a list of what you are sending here.

If you need additional information, I can be reached at telephone number

and/or e-mail address.

I look forward to receiving your response as soon as possible.

Sincerely,

Signature

Typed Name

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 The Pennsylvania Insurance Department’s

Sample letter to request an external review

(adverse benefit determination)

Your Name
Your Address

Date

Address of the Health Plan’s Appeal Department

Re: Name of Insured

Plan ID#:
Claim #:

To Whom It May Concern:

I am writing to request an external review by an independent review organization (IRO) of the

final internal adverse benefit determination I received on date. I have included a copy of that
determination with this request.

I filed my request for an internal appeal on date in response to the denial of coverage for
treatment or service provided by name of provider on date provided. The medical review
upheld the original decision.

 ere is where you may provide more detailed information about the situation. Write
H
short, factual statements. Do not include emotional wording.

If you are including documents, include a list of what you are sending here

If you need additional information, I can be reached at telephone number

and/or e-mail address.

I look forward to receiving your response as soon as possible.

Sincerely,

Signature

Typed Name

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 The Pennsylvania Insurance Department’s

Sample letter to request an external review

(rescission)

Your Name
Your Address

Date

Address the Health Plan Provides You for External Appeal

Re: Name of Insured

Plan ID#:
Claim #:

To Whom It May Concern:

I am writing to request an external review by an independent review organization (IRO) of the

rescission determination I received on date. I have included a copy of that determination with
this request.

I filed my request for an internal appeal on date in response to the original rescission
determination. The medical review upheld the original decision.

 ere is where you may provide more detailed information about the situation. Write
H
short, factual statements. Do not include emotional wording.

If you are including documents, include a list of what you are sending here

If you need additional information, I can be reached at telephone number

and/or e-mail address.

I look forward to receiving your response as soon as possible.

Sincerely,

Signature

Typed Name

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 The Pennsylvania Insurance Department’s

Sample letter to request

review of application denial

Your Name
Your Address

Date

Address of Health Plan

To Whom It May Concern:

I am writing to request a review of the denial of my application for health insurance. I

submitted the attached application on date and received the attached denial on date.

The reason stated for denial was reason stated for denial. I disagree with this reason because:

 ere is where you may provide more detailed information about the situation. If
H
you have supporting documents from a physician, reference them here.

Write short, factual statements. Do not include emotional wording.

If you are including documents, include a list of what you are sending here.

If you need additional information, I can be reached at telephone number

and/or e-mail address.

I look forward to receiving your response as soon as possible.

Sincerely,

Signature

Typed Name

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