Health Plan Disputes: Internal Reviews

Take the first step in fighting a negative decision by your health plan ask for an internal review.

If you believe your health plan was wrong in making a coverage or payment decision including denying coverage, refusing to authorize certain treatment, or billing for questionable charges you have the right to formally request that the health plan take another look at your situation with a internal review. All health plans are required to provide the opportunity for an internal review or appeal if a plan participant disputes a course of action. If you disagree with a decision made by your health plan, an internal review is an excellent (and often necessary) first step toward getting the results you're looking for.

This article discusses the basics of internal reviews, including how to prepare for one and what to do if you disagree with the final decision. (To learn about other ways to challenge a negative health plan decision, see Nolo's article Health Plan Disputes: An Overview.)

Before You File an Internal Appeal

If you disagree with your health plan's decision about payment or coverage, there are some preliminary steps you can take to resolve your dispute informally and ensure that you have all the information that's necessary for a proper appeal.

Review the Contract

The first step is to review your contract and policy carefully. This means digging out the Summary of Plan Description as well as the detailed Evidence of Coverage (you may have to get a copy of the Evidence of Coverage from your employer). Highlight the sections that are pertinent to your dispute.

Call Customer Service

If, after reviewing your policy, you still believe that the health plan erred in its decision, call customer service. An agent may be able to reverse the decision over the phone. If not, the agent can inform you of the next step (most likely, how to file an internal appeal) and mail you the relevant forms.

Start a Phone Log and Save All Documents

Keep a record of the telephone call to customer service as well as all other calls you make related to the dispute. Record these calls in a log: enter the date, time, person with whom you spoke, and the details of the conversation. Save all documents and bills that are related to your dispute and store them together.

Request a Notice of Denial

Ask the customer service agent for a Notice of Denial. This is a formal letter declaring that the health plan is denying coverage and explaining the reasons for the denial.

The Basics of an Internal Appeal

If customer service does not reverse the health plan's decision, it's time to file a formal internal appeal. This is a written request that the health plan change its decision about coverage or payment. It may also be called a "level I appeal" or a "desk review" depending on the plan.

If you don't like the decision from the first level of appeal, most health plans provide you with a second internal appeal. This second appeal usually goes to a panel or committee. Some health plans will allow the consumer to appear at a hearing during this second level.

Preparing the Internal Appeal

The key to success in an internal appeal is preparation. Here's what to do:

Review Your Health Plan Policy and Contract

Your health plan contract (Evidence of Coverage) will contain details on how to file for an internal review. Be sure to comply with all of the requirements, otherwise you'll give the plan an easy way to deny your request. 

Know the Time Limits

The time period in which you must file your appeal varies between health plans. Check on the time limits laid out in your plan, make a note on your calendar, and then file your appeal within the specified period. If you miss the deadline, you may lose your right to fight the decision, and you may be barred from a later external review as well. (To learn about external reviews, see Nolo's article Health Plan Disputes: An Overview.)

Submit Documents

When you file your internal appeal, be sure to include all documents that support your position. These may include:

• medical records
• letters from your doctors (i.e. explaining why certain treatment or procedure should be covered)
• second opinions (opinions from doctors other than your own as to what treatment or procedure is necessary)
• explanation of benefit (EOB) forms applicable to your claim
• references to the applicable sections of the Evidence of Coverage
• additional research on your medical condition (including treatment guidelines and medical journal articles)
• additional research on the cost-effectiveness of the applicable treatment or procedure, and
• evidence of payment (for billing disputes).

Attend the Hearing

Some health plans hold a hearing at the second level of internal appeal. Get someone a friend, family member, advocate, or even a lawyer to help you prepare for the hearing. This person can also attend the hearing to support you.

Arbitration

Sometimes arbitration replaces one of the review levels in an internal appeal. In arbitration, you and the health plan make arguments and present evidence to a neutral third party (the arbitrator) who then makes a decision as to how the dispute should be resolved. (To learn more about arbitration, see Nolo's article Arbitration Basics.)

The Health Plan's Response

The health plan is required to respond to your appeal within a certain time frame. Again, check the Evidence of Coverage for specific time limits under your plan. Federal law governs response times for certain health plans: 30 days if the disputed medical service has not been provided and 60 days if it has been provided. You can ask for an expedited response if you feel you will suffer adverse health effects by not receiving treatment under the timelines specified in your plan. Usually, the health plan must respond within 72 hours to an expedited appeal. If the health plan does not respond to your appeal within the specified time limits, go ahead with the next step in the appeal process (the second level of the internal appeal or an external appeal).

If your request is denied at both levels of the internal review process, you may be able to obtain an independent review called an external appeal. (To learn about external reviews, see Nolo's article Health Plan Disputes: An Overview.)

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).