June 08, 2016

Health Insurance Appeals Rights and Processes

Health Insurance Appeals Rights and Processes


¨ From the Centers for Medicare and Medicaid Services (CMS): "Internal Claims and Appeals and External Review Processes Overview" is a set of slides providing information about a consumer's right to appeal health insurance plan decisions under the Affordable Care Act, including the right to ask that an issuer reconsider its decision to deny payment for a service or treatment, or to rescind coverage. The slides describe:

  • What issuer decisions can be appealed
  • How long consumers have to initiate appeals
  • How consumers must document and submit appeals
  • How consumers can request an expedited appeal timeline in urgent care situations
  • When and how to request an external review by state or federal authorities

These appeal rights and processes apply to consumers enrolled in non-grandfathered qualified health plans through a Health Insurance Marketplace.


¨ From Families USA: When a Bill Becomes a Coverage Appeal: A Basic Overview is an archived webinar (slides and audio; about one hour) about practical ways to approach a plan's explanation of benefits and what to do when a bill becomes a coverage appeal.