What you need to know about the Appeals Process:

From: Helen Dynda (olddad66@runestone.net)
Tue Mar 20 10:58:15 2001

[] What you need to know about the Appeals Process: A primer for patients by the Patient Advocacy Coalition Colorado Ombudsman for Managed Care


Start by asking yourself these important questions.

* Do you need a referral from your primary care physician in order to see a specialist?

* Do you need prior authorization for a planned surgery or hospital stay?

* Do you have to select a physician from a specific network for the charges to be fully covered?

* Are you in a point of service plan? If so, how does it work? What does your plan cover?

* What does it limit or exclude?

If you are enrolled in a health maintenance organization ( "HMO" ), you need to familiarize yourself with the rules of your particular HMO. If you learn the basic rules, and are careful to follow them, you can avoid most denials. However, there are some denials that cannot be avoided. Here's what you need to know if you receive a denial of coverage for treatment:


Understand who has denied the care and get the reason for the denial in writing. What was the basis for the denial? Is the HMO questioning whether the treatment requested is medically necessary? Is it a covered benefit? Is it being deemed experimental or investigational?

An HMO will first check to see whether the treatment requested is a covered benefit. If it is a covered benefit, it must also be medically necessary in order for it to be approved.

If your denial letter states that the treatment requested is not a covered benefit, check your benefit plan or summary to determine whether the treatment requested is, in fact, an exclusion. If it is an exclusion, be prepared to argue why they should make an exception for you.

If your denial letter states that the treatment requested is not medically necessary, you should ask your physician to write a letter to the HMO explaining the medical necessity of the treatment requested. In addition, you should consider getting a second opinion, so that you can submit a second physician letter in support of the treatment.

Check the denial letter and the benefit plan or summary to see how much time you have to appeal the denial.

It is normal to feel discouraged by the denial and overwhelmed at the prospect of filing an appeal. Give yourself a few days, if necessary, to recover from the initial disappointment, and to develop an appeals strategy.

No, does not necessarily mean no when you hear it from an insurance company; it means probably not. It means the HMO has shifted the burden to you and your physician to try to prove to the HMO's decision-makers why they should pay for the treatment you are requesting. Many people are easily deterred by such a challenge, and they either go without treatment or they pay for it themselves. However, with a growing number of us joining HMOs, it is wise to know how to challenge critical decisions affecting your health care with which you disagree.


Did the denial letter come from your HMO? Or did it come from an independent physician association ( "IPA" ), the larger physician's group to which your physician belongs? You need to call the entity that sent you the denial, if you want more information. When making your call, have a file in front of you that contains all of your medical and insurance information, including your benefit plan or summary. If you want to discuss the merits of your case, try to speak with a decision-maker, such as a utilization manager or medical director. A customer service representative cannot overturn a denial.

Keep a written record of all communications with HMO personnel, including the date and time of your conversation, the full name and title of the person with whom you spoke, and a summary of what was discussed. If you are given an approval or other information that is helpful to your case, send a certified confirmation letter to the health plan that details your understanding of what was said. Always record the authorization number for a procedure, if it is given to you over the phone.

Throughout your conversations, resist any temptations to get angry or frustrated, and remain friendly, polite, firm and informed. Be assertive without being aggressive. The HMO employees will probably be more inclined to assist you if you are treating them courteously.

If you are not able to resolve the matter with a telephone call, it is time to consult your benefit plan or summary for directions on using the appeals process.


Every HMO is required, by law, to have an appeals process.

The problem is that it is an unfamiliar process to most people. If you don't know what to expect, you can't prepare properly. That decreases your chance of overturning the denial.

By reading this information, you will learn what to expect and how to prepare properly. That increases your chance of overturning the denial.

Typically, the HMO will want your complaint in writing. The letter can come from you or from your physician. If it comes from you, try to give specific reasons as to why the treatment was requested, and get a support letter from your physician(s). Your physician will find it helpful if you give him/her a copy of the page in your benefit plan that describes the type of treatment that was requested and the situations in which it will be approved or denied. You should also provide your physician with a copy of the denial letter from the HMO, if he/she did not receive one, and a copy of your letter to the HMO, so that he/she can provide clinical support for your contentions. Give your physician as much lead time as possible.

Your letter should include: the symptoms or health problems you have been experiencing and for how long; your treatment history, and how you have exhausted any other reasonable treatment alternatives; your physician's recommendations, and why you are an ideal candidate; and what will happen to your health if the treatment is not approved. Quote from your benefit plan if it contains helpful language, and identify the page on which the quote can be found. Attach any medical records that support your position.

If you are in a commercial HMO, and your denial was based on medical necessity or on the treatment being identified as experimental/investigational, you are entitled to the following:

Either a first-level appeal review by a physician who was not involved in the original decision to deny your request, in consultation with someone who would typically manage the kind of case being reviewed, AND / OR

A second-level appeal to a review panel selected by the HMO. The panel shall include a minimum of three people. The panel may be composed of employees of the HMO who have "appropriate professional expertise."

If you are given a first-level appeal review, a determination letter should be sent to you within twenty days of your appeal request. The letter should include the name, title and qualifications of the physician who evaluated the appeal; the reason for the appeal; the reason for the decision; and information on how to file a second-level appeal.

If your HMO eliminates the first-level, and sends the appeal directly to a review panel, the panel must hold a meeting to review your second level appeal within forty-five days of receiving your appeal request.

You have a right to appear in person before the panel. We highly recommend that you do so. It is harder for the panel to say no once they have met the person requesting the treatment. Make sure your HMO knows that you intend to appear in person, and request that the panel members be physically present rather than participating telephonically.

If you live too far away to appear in person, the plan must pay for you to present your case by conference call, teleconferencing, or other technology.

You have the right to present written materials to the panel. You should submit any such materials well in advance of the meeting, so that the HMO can copy them and distribute them to be read in advance of the meeting. Do online searches, go to a medical library, or ask your physician for articles from medical journals that support your treatment request. ( Make sure you understand the results of treatment studies before including them in your appeal! ) Call medical specialty organizations to ask if they have position papers or guidelines on the type of treatment you are requesting.

Request a copy of any information the HMO is providing to their panel members in connection with your case. Check to make sure that the information you want the panel members to see has been included. Also check for any guidelines or protocols which the HMO might have employed in making their decision.

One of your HMO's concerns is the cost of the treatment. Look for information that will show how the treatment being requested is a cost-effective alternative to something that would be covered. Show how the treatment may cost less over time than a different treatment option and be better financially for the HMO.

You have the right to be assisted by a person of your choice. This can be an attorney, but you must notify the HMO of that fact at least five working days in advance of the meeting.

You can bring "witnesses" with you to speak on your behalf. Physicians and family members are typically asked to attend. Someone who cannot attend due to a scheduling conflict may be able to participate telephonically. Strongly urge your physician to at least participate telephonically. Invite "witnesses" who are persuasive and knowledgeable, and be mindful of the amount of time you have been allotted by the HMO, which is usually 15 to 20 minutes. If you will need more time, request it in advance.

You must be notified of the panel's decision within five working days of the meeting. The letter must include the names and titles of the panel members a summary of the reason for the decision, including the medical reason; and notice of additional appeal rights.

If the panel denies your claim, you can request an independent external review. The external reviewer may NOT have been involved previously in your care; be a member of the board of directors of the HMO; have been previously involved in the review process; have a direct financial interest in the case; or be an employee of the HMO.

The expert reviewer shall be an expert in the treatment of the medical condition of the person appealing, and be knowledgeable about the requested treatment through their own clinical experience. You can challenge the appointment of a particular expert if he/she does not meet these stringent requirements.

The expert reviewer can review denials based on medical necessity. However, the expert reviewer can only review experimental or investigational procedures that are not explicitly listed as an excluded benefit in the policy. Benefit denials are not reviewable by the external reviewer.

An independent external review must be requested within sixty calendar days after receiving notification of a second-level appeal denial.

The external review must be completed within thirty working days after the HMO received the request for an external review.

The determination shall be in writing and shall include: the credentials of the reviewer; a statement of the facts; the rationale for the decision; reference to medical evidence; and in the event of a denial, instructions for requesting the clinical rationale for the decision.

The expert reviewer's determinations are binding on the HMO and binding on you.

Keep in mind that this process can be expedited when necessary. If the normal time frame would jeopardize your health, you can ask for a first-level appeal decision within 72 hours. Physician support for the urgent nature of the appeal is helpful. You can also skip the internal process and go straight to the external review if there is an emergency. That determination must be provided within seven working days after the request for an expedited external review. If additional information is required, these deadlines can be extended by the reviewers.

Strategically, expediting the process may or may not be advantageous for you. The panel has the opportunity to meet with you and your physician(s), and may show more flexibility in its decision-making as a result. The expert reviewer only receives a file, and is unlikely to contact you or your physician(s) with questions or concerns.

If your situation is not an emergency, you should consider whether changing health plans would be advantageous for you. You should research other options carefully, however, so that you do not switch and then find yourself in the same situation.

It is important not to let your health deteriorate during the appeals process. The appeals process can be used retrospectively, as well as prospectively. If you can afford to pay for the treatment, you can always get the treatment and then challenge the denial. Retrospective appeals are more difficult to win, because the emotional aspect of the case has been resolved, but they are always an option.

Your physician is an integral part of the appeals process, and has a vested interest in helping you to obtain the treatment that he or she has recommended. Enlist your physician's help, and keep him or her informed about your efforts. If your physician is reluctant to advocate for you, you may want to consider switching to a physician who takes their advocacy responsibilities seriously.

Monitor the response time of your HMO to ensure that your complaint is moving forward expeditiously. Jot down relevant dates for filings or responses and call the HMO if target dates are missed.


There are all different kinds of health insurance, and they have different appeal processes. What kind of insurance do you have? Are you in a self-insured plan? If you have a group policy, and (a) your employer has direct responsibility for medical costs, and (b) uses an outside carrier for administrative purposes only, you are in a self-insured plan. Ask someone in the benefits/human resources department about this; they should know the answer. If you are in a self-insured plan, federal law applies and the Department of Labor can oversee your complaint. If you are in a self-insured plan, you may not be entitled to the second-level of the appeals process, or to the independent external review. You need to check your benefit plan for information about the appeals process. Typically, in a self-insured plan, the employer retains the ultimate decision-making authority.

Are you in a Medicaid managed care plan? If you are in a Medicaid managed care plan, such as the Primary Care Physician Program or a Medicaid HMO, and you have received a denial, you have the same process described earlier, but with two exceptions: (1) you can verbally request the first and second- level reviews and (2) instead of having an independent external review after the second-level panel, you can appeal to an Administrative Law Judge. The Patient Advocacy Coalition, as Ombudsman for Managed Care, can assist you with the appeals process at no charge. Their telephone number is (303) 744 - 7667.

Are you in a Medicare HMO? If you are in a Medicare HMO, and you have received a denial, you have the same process described earlier, but with several exceptions: (1) the timeframes are mandated by the Health Care Financing Administration ("HCFA") and may differ from state law; (2) your independent external reviewer is the Center for Health Dispute Resolution, which has a contract with HCFA to review Medicare HMO denials; (3) if the independent reviewer upholds the denial, you can request a hearing with an Administrative Law Judge with the Social Security Administration; and (4) if denied again, and the amount for the service or procedure in question is $1000 or more, you can request judicial review through the federal district court. If you have questions about the Medicare appeals process, you can call Centura Health Insurance Counseling for Seniors at (800) 544 - 9181.

Are you in a commercial plan? If you are in a commercial plan, whereby the HMO has direct responsibility for medical costs, the appeals process described earlier is available to you pursuant to state law. In addition, if you are appealing a denial, you can consider filing a complaint with the Colorado Division of Insurance. You can complain about the denial itself, or about your HMO violating your appeal rights by not adhering to the proper steps of the appeals process. Submit your complaint in writing and ask them to investigate the matter. As a state regulatory agency, they have the authority to enforce applicable insurance laws and to require compliance. They can also impose penalties, such as fines, on non-compliant HMOs. Their address is 1560 Broadway, Suite 850, Denver, Colorado 80202. Their telephone number is (800) 930-3745. Their website is http://www.dora.state.co.us/insurance .

No matter what type of coverage you have, another important resource is the Patient Advocacy Coalition, a national organization based in Denver. The Patient Advocacy Coalition helps people to navigate their way through the appeals process. If you have questions about the appeals process, the Patient Advocacy Coalition operates a free telephonic assistance program that can help you to understand the process, your rights, and strategies for presenting a persuasive and compelling appeal. The Coalition, which was founded by a former trial attorney, can also represent you in the appeals process for a nominal charge. The Coalition can be reached at (303) 744 - 7667 or, if you reside outside of metro Denver, at (877) HELP 123.

DON'T GIVE UP! Although the process may require a significant amount of effort on your part, it is a worthwhile endeavor to remain in control of your health care, and to challenge decisions affecting your health care with which you disagree.

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