Guide Frequently Asked Questions about Internal Appeals

Contact your health insurance company to request an internal appeal. See below for a list of OPP’s most frequently asked questions about internal appeals.

What is an internal appeal?

When you receive health care, your doctor or health care provider requests payment or prior authorization from your health insurance company. Your health insurance company may refuse to pay for or authorize the service or treatment. If so, your health insurance company will send you a denial notice or explanation of benefits form explaining why the health insurance company refuses to pay or authorize. You may ask your health insurance company to reconsider that decision by requesting an internal appeal.

When can I request an internal appeal?

You have 180 days from the date of the denial notice or explanation of benefits form to request an internal appeal.

Who should I contact to request an internal appeal?

You should contact your health insurance company directly to request an internal appeal. The denial notice or explanation of benefits form should have information about internal appeals. If not, you should read your member handbook or call your health insurance company to learn how to submit an internal appeal.

How much time will it take to decide my internal appeal?

Your health insurance company must resolve your appeal in writing within 30 calendar days of receiving your request for an internal appeal.

If your appeal requires the review of medical records, the 30 calendar day timeframe begins as soon as you submit a signed release form to the health insurance company.

Can my health insurance company delay the internal appeal process?

No. Unless you agreed in writing to extend the time frame, your health insurance company must make a decision within 30 calendar days.
 

What if my health insurance company fails to respond to my internal appeal within 30 calendar days?

If the health insurance company does not provide a written resolution within 30 calendar days, then the health insurance company must pay for the treatment or service that was originally denied. No external review is necessary.

Is the health insurance company ever required to act in less than 30 days?

The health insurance company must decide the internal appeal faster when you are appealing coverage of immediate and urgently needed services and you request an expedited internal appeal. In this case, your health insurance company must resolve your appeal in writing within 72 hours of receiving it. If you think this applies to you, request an expedited internal appeal from your health insurance company.  

Does my appeal need to be in writing?

No. Your health insurance company must accept your appeal by phone, by mail, in person, by fax, or by e-mail.

Also, if you submit your appeal orally, the health insurance company must send you a written summary of your complaint within 15 days of receipt.

Will my health insurance company pay for treatments and services during the appeal process?

If your appeal deals with ongoing services or treatment, those services or treatments must be covered by the health insurance company until the end of the internal appeal. In addition, your health insurance company must continue to pay for your other medical care in the normal course of business.

How will the health insurance company respond to my appeal?

Within 30 calendar days, the health insurance company must provide you with a written response. Your health insurance company will send you a final adverse determination letter if the health insurance company decided that the treatment or service is not medically necessary, and therefore will not pay for or authorize it.

What happens if I receive a final adverse determination letter in response to my appeal?

If your health insurance company still refuses to pay for or authorize the treatment or service by issuing a final adverse determination letter following the internal appeal, you may be able to request an external review of that decision through the Office of Patient Protection. You have 4 months from receipt of a final adverse determination letter from your health insurance company to request an external review.

Where can I get assistance in requesting an internal appeal?

Health Law Advocates, 617-338-5241 provides free legal assistance to people who meet income guidelines and other acceptance criteria.

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