Most states have an external review program that lets a consumer appeal a health plan's negative decision after an internal review. In a few states, these programs are available only for disputes with managed care plans (like HMOs and PPOs).
The type of health plan you have dictates whether you are entitled to an external review (also called an independent review) of your dispute. You can usually get an external review if you are:
You are not entitled to external review if you are enrolled in a self-funded employer-sponsored plan. This means you have health insurance through your job and your employer pays for the health care costs of its employees directly, rather than purchasing insurance from an insurance company. (To determine which type of plan you have, see Nolo's article Understanding Your Health Insurance Coverage.)
The procedures in an external review of a health dispute vary by state. That means you'll have to review your policy to find out what types of disputes are eligible for review, the time limits for bringing a complaint, and how to proceed with your appeal. In most cases, you must complete the internal review process before you can ask for an external review. The external review is usually available for free or a small charge. Most states allow the consumer to give written authorization to let a third party (for example, a medical provider) file the appeal.
Unlike the internal review, an external review is usually limited to determinations of what is a "medical necessity." That means the dispute must involve a procedure, treatment, or prescription drug that you and your doctor believe is essential for your health, but your health plan disagrees. For example, your doctor believes that a new prescription drug is essential to treat your asthma, but your insurance plan's position is that the drug is experimental and hasn't been shown to help asthma patients.
For the most part, you cannot obtain an external review of a coverage issue (like whether your fertility treatment falls within your plan's definition of covered procedures).
In most states, the review panel does not conduct a hearing. Instead, you must submit all your evidence and arguments in writing. Be sure to read the external review requirements carefully and submit everything that is requested.
According to the Health Care Marketplace Project, many external appeals are denied because:
If you want the panel to consider your appeal, make sure you have met all preconditions and that your issue is appropriate for external review.
If an internal or external review of your health plan dispute doesn't give you the results you were looking for, you may be able to sue your health plan in court. Whether you're allowed to go to court often depends on the type of plan you have and the state where you live. Determining whether you can sue an insurance company can be complicated -- and the lawsuit itself is sure to be complex as well -- so it's wise to seek the advice of an attorney who specializes in insurance cases.
For help in choosing a good attorney, read Nolo's article How to Find an Excellent Lawyer. For help in choosing a good attorney, use Nolo's Lawyer Directory for a list of insurance attorneys near you (click the "Types of Cases" and "Work History" tabs to find out about the lawyer's experience, if any, with medical insurance cases).
The following applies only to patients who have a dispute with an HMO. Many HMOs are accredited by an independent organization such as the National Committee for Quality Assurance (www.ncqa.org), the American Accreditation HealthCare Commission/URAC (www.urac.org), or the Joint Commission on Accreditation of Health Care Organizations (www.jcaho.org). Because HMOs want to remain in good standing with these groups, filing a complaint with an accrediting organization might spur the HMO into resolving the issue to your satisfaction.
Also for HMO patients: Most HMOs are licensed by a state insurance department. So filing a complaint with your state's insurance department may spur the HMO into action or might even prompt the department to intervene in your dispute.
To learn about managing health care expenses and dealing with other pressing financial issues, get The Busy Family's Guide to Money, by John Waggoner, Kathy Chu, and Sandra Block (Nolo with USA Today).
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