A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan
| < Return to Report Index | | WHEN YOU CAN APPEAL
If you have a dispute over whether your health plan will pay for a particular treatment, you may have to proceed with treatment before knowing if the plan will pay for it. In many states, you will be able to submit your dispute for external review even if the services have been provided; in others you may submit your case only if services have not been provided.
Most states require you to complete all of the steps in your plan’s internal appeals procedure before requesting external review. Some states specify time limits for the internal review, and some allow you to file for external review if you have not received a response within the required time. At least one state, New Mexico, allows you to file for external review at the same time you appeal to the health plan if your case is an emergency.
If you have completed all steps in the internal appeals process, and you have not won your case, you will receive a notice of "adverse determination" or "adverse decision" from your health plan, along with instructions on how to file with the state for external review. You usually must file within a specified period, say 30 to 90 days, after receiving the adverse determination in order to be eligible for external review.
If a delay in receiving services will cause you serious harm, most states have what is called an "expedited review" which will give you a decision in a much shorter period, usually 24 to 72 hours. Your provider must certify that the needed care is an emergency, and sometimes the state agency must agree.
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