If your health insurance provider refuses to pay a claim, you have the right to appeal their decision and gave it reviewed by a third party. Your insurance company has to tell you why they’ve denied your claim and they have to let you know how to dispute their decisions.
Here are two ways to appeal a health insurance provider decision:
Internal appeal: If your claim is you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
- You file a claim: A claim is a request for coverage. You or a health care provider will usually file a claim to be reimbursed for the costs of treatment or services.
- Your health plan denies the claim: Your insurer must notify you in writing and explain why:
- Within 15 days if you’re seeking prior authorization for a treatment
- Within 30 days for medical services already received
- Within 72 hours for urgent care cases
- You file an internal appeal: To file an internal appeal, you need to:
You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, you can ask for an external review at the sametime as your internal appeal.
If your insurance company still denies your claim, you can file for an external review.
External review: You have the right to take your appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.
1. You file an external review: You must file a written request for an external review within four months after the date you receive a notice or final determination from your insurer that your claim has been denied.
2. External reviewer issues a final decision: An external review either upholds your insurer’s decision or decides in your favor. Your insurer is required by law to accept the external reviewer’s decision.
Cosmo Insurance Agency is an independent insurance agency serving surrounding communities in New Jersey. Cosmo keeps its promise to assure an efficient and creative approach to the services we offer. Each of our clients experience a personalized and long-term relationship with us. Our New Jersey based team of health brokers guides our clients in helping them choose the most cost-effective options. By incorporating the latest in technology-based tools and laws on healthcare, employee benefits, life insurance and finance, we keep our clients up-to-date with the plans that encompass all of their needs, whether it is individual or group insurance.
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