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What is an Insurance Health Appeal? How Does the Process Work?

If your health insurance claim is denied, you have the right to appeal that decision.  You will first appeal the decision within the internal channels of the insurance company, and if your claim is still denied, you can then file for external review from the state insurance department.  Depending on the circumstances, you may also be able to file a lawsuit against the insurer.

Internal Health Insurance Appeals

When you file a claim with your health insurance company, your insurer is required to complete its investigation and render a decision on your claim within a certain period of time.  That time period depends on the nature of the claim (whether it is a claim for desired treatment, whether it is a claim to reimburse treatment already received, whether it is for urgent or emergency care).  If they decide to deny your claim for coverage, they are required to issue a notice of denial explaining their reasons for denying your claim.  Once you receive your notice of denial, you have the right to file an appeal.

Your notice of denial should specify how you can pursue an internal appeal, including the required documentation and your time frame for doing so.  You can file the appeal yourself, with the help of an attorney, or though your health care provider’s office.  Your appeal should include details about your claim, the reasons for denial, your policy, evidence supporting your claim including your medical records, a supporting letter from your physician, and your reasons for believing the denial was wrongful.  If you need treatment urgently, you can request expedited review.

Once you notify your insurer of your appeal, they have a set period of time to review your claim internally and render a new decision on the matter.  They typically have 30 days if you are requesting prior authorization, 60 days if you have already received the treatment, or 72 hours if your case is urgent.  If they need additional time to decide, they must notify you in writing.

If your insurer takes too long to render its decision, or if they deny your claim once again after appeal, you can petition for an independent medical review from a neutral healthcare professional.   Where you file your independent medical review and which California agency takes the lead depends in turn on the nature of your healthcare plan.  A knowledgeable California insurance denial attorney can assist you in seeking independent review after an unsuccessful internal appeal.

Fight a Wrongful Insurance Denial With Help from Gianelli & Morris

If you are a California insurance policyholder or beneficiary and you have had a claim wrongfully denied, or if you have been subjected to bad faith conduct by an insurance company, call the insurance law attorneys Gianelli & Morris for a free consultation regarding your case.

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