Frequently Asked Questions about Internal Appeals

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.

You have 180 days from the date of the denial notice or explanation of benefits form 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.

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.

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

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.  

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.

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.

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.

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.

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

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