Appeals

There are a couple of things you should consider.  What type of plan is it – fully or self-insured?  If you bought your insurance yourself, maybe through a broker or through Access Health CT, Connecticut's health insurance exchange, then it’s fully insured.  If you get it through an employer, it could be self-insured.   This is important because fully insured plans must comply with both federal and state law, while self-insured only need to comply with federal law. 

What does this mean to you?  If Connecticut passes a law about what should be covered, or how an insurance plan should manage your benefits and claims, self-insured plans do not have to follow that law - they are only subject to laws passed by the Congress or federal regulations. 

For example, in Connecticut, the law states when a mammograms shows heterogeneous or dense breast tissue, the insurance must also cover an ultrasound and an MRI.  However, even if the initial mammogram was a free, preventative mammogram that, under the Affordable Care Act should cost you nothing,  the ultrasound or MRI would be subject to your normal plan design.  This means that, even if the mammogram was free, if you need an ultrasound or MRI because the mammogram didn't provide a clear enough image for the doctor to determine if there are any abnormalities of concern, you may have to pay for them.  If you have a deductible, the charges for the ultrasound or MRI would be applied to that before the insurance would pay.  If you normally have a co-pay for this type of service, you would still have to pay that, although Connecticut law does limit the co-pay for ultrasounds in these circumstances to $20. 

If you have a self-insured plan, then it is not required to even cover an ultrasound or MRI in this situation unless it determines that it is medically necessary, and even then, can apply whatever costs would normally be associated with that type of service.

Types of appeals

Internal Appeals

All insurers must allow for a first level internal appeal for a denial of some benefit, and many also allow a second level internal appeal, which is often voluntary.  An internal appeal is when the insurer has other staff review the claim and denial, along with any information submitted with the appeal, to determine if the requested treatment should have been covered.  You will typically have 180 days from the date of the initial denial to file a first level appeal.  You must submit your appeal within the timeframe stated on your denial, or the insurer may refuse to accept the appeal, which will result in the loss of all other options for appealing the denial of coverage.  If, for some reason, you cannot submit the appeal on time - perhaps you haven't received some records you need for the appeal - you can contact the insurer and request an extension, although they are not obligated to grant one.

Should the first level appeal uphold the initial denial, the timeframe to submit a second level appeal, when one is available, will vary, but is usually no less than 60 days after the first level appeal was upheld.

External Appeals

In addition, if the insurer refuses to change their decision, and upholds the denial of coverage through the first and second level appeals, you may have an opportunity for one final review of your request for coverage.

For a denial that is based on: a) a lack of medical necessity ( when the insurer feels that the clinical record doesn’t support the need for the requested service), or b) the experimental/investigational nature of the requested service (when the insurer feels that the service does not have adequate clinical, academic, peer-reviewed support for its effectiveness in treating a given condition) you have a final appeal opportunity for an independent external review, where a medical professional with experience in the area of medicine that you've been denied, and who does not work for the insurer, will review your case and determine if the service should actually be covered.   The decision of the external reviewer is binding, and if they determine that your service was improperly denied, they can order the insurer to pay.  However, if they determine that the insurer's decision was proper, based on the information they've received for review, they will uphold the denial, and no additional appeal options remain.

It is important to understand that there are different processes for requesting an external appeal depending on whether you insurance is self or fully insured. 

Details about your rights and how to initiate any available level of appeal of a denied service must be included in the letter you receive from the insurer, so be sure to review and keep all pages of any letters you receive.

Remember that the Office of the Healthcare Advocate is available to help guide you through this process or, if you prefer, to advocate and appeal directly on your behalf.  If you would like to discuss this with one of our dedicated staff, please contact us.