When your plan denies a claim, it is required to notify you of:
- The reason the claim was denied
- Your right to file an internal appeal
- Your right to request an external review if your internal appeal was successful
- The availability of a Consumer Assistance Program (CAP) that can help you file an appeal or request a review (if your state has such a program)
If you don’t speak English, you may be entitled to receive appeals information in your native language upon request.
When you request an internal appeal, your plan must give you its decision within:
- 72 hours after receiving your request when you’re appealing the denial of a claim for urgent care. (If your appeal concerns urgent care, you may be able to have the internal appeal and external review take place at the same time)
- 30 days for denials of non-urgent care not yet received
- 60 days for denials of services you have already received
If after an internal appeal the plan still denies your request for payment or services, you can ask for an independent external review. Your plan must include information on your denial notice about how to request this review. A CAP program can help with this request. If the external reviewer overturns your insurer’s denial, your insurer must give you the payments or services requested in your claim.
These new rules apply only to new plans (purchased or created after March 23, 2010). Grandfathered plans do not have to comply with the new rules.