Each insurance company is different, and not every claim may be covered. Here’s what to do if your insurer denies a claim for arthritis-related care or other health services.
File an Internal Appeal
Ask your insurance company to review its decision. You must do this within 6 months after learning your claim was denied.
To file an internal appeal:
• Review the appeals process, which should be outlined in the rejection letter from your insurance company.
• Fill out the appeal form(s) your insurance company provides.
• Ask your doctor to write a letter or provide other background material to help your case.
• Keep copies of all forms, as well as notes from phone conversations with your doctor and insurance company.
• You can also ask the Consumer Assistance Program in your state to file an appeal for you.
Once the internal appeal review is finished, you should get a written decision in 30 to 60 days. If the claim involves a serious health issue, ask the insurance company to speed up the process.
Get an External Review
If your appeal is rejected, you can ask for an external review of your claim. That means an independent person outside of your insurance company will do the review.
To request an external review:
• Submit a written request for external review form within 60 days of the date you received the insurance company’s decision.
• Or, ask a doctor or other medical professional to request the review for you by filling out an Appointment of Representative form.
If external review is in your favor, the insurance company will have to pay the claim. However, the reviewer may stick with the insurance company’s original decision.
For general information about filing appeals, go to: www.healthcare.gov/contact-us
To find your state’s Consumer Assistance Program, visit: www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/#statelisting
To start the external review process, call: 877-549-8152 or visit: www.externalappeal.com
To get help filing an internal appeal or external review, visit your state’s Department of Insurance: www.naic.org/state_web_map.htm